Highlights of the Health Equity Needs, and Challenges in AANHPI Communities

By Sumedha Gulati

This month, the California Association of Healthcare Leaders Justice Equity Diversity and Inclusion Committee celebrates the cultural and historical contributions of generations of Asian Americans, Native Hawaiians, and Pacific Islanders (AANHPI) to the United States. For healthcare leaders, it is an opportunity to reflect on this diverse set of communities’ health equity needs and challenges as demonstrated by demographics, healthcare disparities, and COVID-19 pandemic experiences. 

Demographics

Per the 2020 US Census, over 24 million or 7.3% of the US population is Asian American. 

• The communities are very heterogenous as they include approximately 50 ethnic groups speaking over 100 languages, and reflect both US born and immigrant populations.  
• The largest Asian American groups are: Chinese (5 million), Asian Indian (4.5 million), Filipino (4.1 million), Vietnamese (2.2 million), Korean (1.9 million) and Japanese (1.6 million)
• Asian Americans are already the fastest-growing racial/ethnic demographic in the country, with their size nearly doubling between 2000 and 2019
• By 2060, Asian Americans are projected to be the United States’ largest immigrant group, with their numbers estimated to surpass 46 million, or more than 10 percent of the total U.S. population
• Nearly 30% of Asian Americans have limited English proficiency 

Per the 2020 US Census, 1.6 million or 0.48 % of the US population is Native Hawaiian and Other Pacific Islanders.

• NHPI population includes 31 groups categorized into the four large categories of Polynesian, Micronesian, Melanesian, and Other NHPI
• The largest NHPI groups are: Native Hawaiian (680,442), Samoans (256,997) and Chamorro (143,947) 
• From 2010 to 2020, the Native Hawaiian and Samoan populations grew by 29.1% and 39.3%, respectively
• About 12% of Native Hawaiians and Pacific Islanders have limited English proficiency

Approximately 30% of the US AANHPI population lives in California  

• AANHPI residents comprise roughly 15.5% of California’s population or 6 million
• According to 2020 US Census data, CA AANHPI population grew by 25 percent in the past decade, faster than any other ethnic group in the state

Healthcare Disparities Data Disaggregation and Community Engagement

Several national and state level resources, and published research are available for healthcare leaders to better understand the AANHPI health disparities in access to care, clinical and behavioral health, and underlying social determinants of health (see resources at the end of the article.) 

However, much of the data on this ethnically diverse population are aggregated, leading to hidden health disparities within some of the ethnic groups. When examining service- or market area-specific AANHPI population data, it is critical that healthcare organizations disaggregate the data further by subgroups as this category includes several variables that influence these hidden disparities. These variables include multiple languages, religions, cultures, and historical experiences ranging from colonization, immigration, to war-trauma refugee.  Identifying and understanding these hidden health disparities enhances our understanding of AANHPI health behaviors, beliefs, and access and care challenges.

Also, healthcare organizations can enhance the design and evaluation of their clinical service, chronic disease management, and/or community health programs by engaging and collaborating with the local AANHPI communities and AANHPI focused community-based organizations in data collection of outcomes and measures. Community organizations have rapport and trust with AANHPI communities that gives them greater accessibility into AANHPI communities. This also builds trust between healthcare organizations and AANHPI individuals and communities.

Access to Care 

The Affordable Care Act had a significant impact on reducing the number of uninsured nationally and across various populations.  

• The uninsured rate for the AANHPI population decreased from 14.7% in 2013 to 6.8% in 2019. This 54% reduction in the uninsured rate was the largest improvement among any racial or ethnic group during this time period
• Uninsured rates varied greatly among AA and NHPI subgroups, ranging from 2.8% for Japanese Americans to 10% for Korean Americans and 12.3% for Native Hawaiians and Pacific Islanders in 2019
• Large health insurance related disparities also exist among limited English proficient, less educated, low income, or immigrant AANHPI populations

As of 2021, among the nonelderly population, 6% of AA and 11% of NHPI were uninsured (vs. 7% for non-Hispanic White)

• The shares of AA people covered by private coverage were higher than the shares for non-Hispanic White and the shares covered by Medicaid were lower
• NHPI were less likely to have private coverage and more likely to be covered by Medicaid, with over half (52%) of NHPI children being covered by Medicaid or the Children’s Health Insurance Program

Clinical Health 

Some notable AANHPI clinical health disparities are:  

• Cancer, especially of the stomach and liver, are the leading causes of death. 
• High rates of tuberculosis and Hepatitis B (30x higher than non-Hispanic whites)
• Higher rates of diabetes, obesity, and cardiovascular disease compared with non-Hispanic whites. 
• Disparities in prevention and early detection interventions center around health screening and preventive health-seeking behaviors, which are lower among AANHPI in comparison to non-Hispanic whites.
  • For example, Asian Americans have lower rates of cancer screening than other Americans

Disease prevalence rates for specific AA and NHPI subgroups are limited, but certain select studies demonstrate large health disparities among the subgroups.

• The rate of diagnosed diabetes was 9.2% for Asian Americans, compared to 7.6% for non-Hispanic Whites in 2017-18, but as high as 12.2% for Asian Indians and 10.4% for Filipinos and as low as 5.6% for Chinese
• Cervical cancer incidence rates were 7 to 10 times higher for Vietnamese, Samoans, and Laotians, compared to non-Hispanic Whites in 1998-2002

Behavioral Health 

According to the 2021 National Survey on Drug Use and Health:

• The percentage of Asian Americans and Native Hawaiian and Pacific Islanders who reported having any mental illness in 2021 was 16% and 18%, respectively
• Only 25% of Asian Americans received mental health services compared to non-Hispanic Whites (52%)
• Eight percent of Asian Americans and 15.7% of Native Hawaiian and Pacific Islanders reported having a substance use disorder, 11% of Asian Americans reported illicit drug use in the past year, and 7% reported unmet treatment needs

Suicide was the leading cause of death among AANHPI ages 10 to 19 and the second leading cause of death among those ages 20-34

In California: 

• While Asian American and Native Hawaiian and Pacific Islander communities reported the lowest rates of suicidal ideation overall, disaggregated data reveal Japanese, Korean and U.S.-born Asians are more likely to have said they had ever thought of committing suicide.
• Among those who reported needing help for emotional, mental or addiction problems in the past year, Asians, along with Blacks and Hispanics, were significantly less likely to receive needed mental, emotional or addiction treatment than whites. Disaggregated data for Asians show similar challenges in accessing mental health services, especially for Vietnamese communities.

Underlying these statistics are the following barriers to behavioral healthcare for AANHPI:

• Mental health stigma and cultural conceptualizations of behavioral health within Asian American communities
• Perceived lower need of mental health care among Asian Americans compared to other racial and ethnic groups
• Language barriers make it difficult for Asian Americans to access behavioral health services
• Shortage of clinicians with diverse racial/ethnic backgrounds
• Lack of culturally competent medical providers to meet cultural, social, and language-related needs

Impact of COVID 19

The AANHPI communities were uniquely impacted by the COVID-19 pandemic. 

• “A high proportion of Asian Americans were at an increased risk for COVID-19 exposure and infection due to their work in high-contact essential occupations in health care such as physicians, nurses, healthcare technologists, cooks and food preparation servers and supervisors.”
• “Asian American business communities sustained some of COVID-19’s worst economic impacts as Asian-owned businesses were a large percentage of the sectors hit hardest by COVID-19, such as accommodations and food service, retail trade, and education-services businesses.”
• Asian Americans disproportionately experienced a rise in mental health challenges, partly due to the increase in anti-Asian racial discrimination.10 Per the Center for the Study of Hate and Extremism, anti-Asian hate crimes increased by close to 150% in 2020.

In California, NHPIs had the highest COVID-19 death rate (182 per 100,000) compared to all other racial and ethnic groups

• The pandemic increased the rates of depression, anxiety, substance addiction, and distress among NHPI adults13 
• NHPI adolescents reported increased social isolation and deferred their academic goals, all of which impaired their mental health

Conclusion

These data highlight key characteristics of some of the healthcare inequities that affect various AANHPI groups. Common challenges for AANHPI include navigating the health care system and accessing culturally and linguistically appropriate services.  Also, each subgroup faces unique healthcare inequities that can be identified through data disaggregation and community engagement. The AANHPI COVID-19 pandemic experience emphasizes the urgency to address AANHPI mental health equity needs.

Finally, these highlights serve as a starting point for healthcare leaders to incorporate community-specific research to design culturally and linguistically appropriate services to meet the diverse healthcare needs of AANHPI populations.

Sumedha Gulati, MPH, MBA, is an independent advisor in strategic/business planning and implementation,organizational process and performance improvement, and broad scale portfolio, program, project, and operations management. She serves as a member of the Justice, Equity, Diversity, and Inclusion committee and Vice Chair, Valley Local Programming Council, for CAHL. Find her on LinkedIn here.