Neighborhood Ethnic Composition and Self-rated Health Among Chinese and Vietnamese American Immigrants

Social Determinants of Health and Insurance Claim Denials for Preventive Care

Importance

The Patient Protection and Affordable Care Act (ACA) eliminated out-of-pocket cost-sharing for recommended preventive care for most privately insured patients. However, patients seeking preventive care continue to face cost-sharing and administrative hurdles, including claim denials, which may exacerbate inequitable access to care.

Objective

To determine whether patient demographics and social determinants of health are associated with denials of insurance claims for preventive care.

Design, Setting, and Participants

This cohort study of patients insured through their employers or the ACA Marketplaces used claims and remittance data from Symphony Health Solutions' Integrated DataVerse from 2017 to 2020; analysis was completed from January to July 2024.

Exposure

Seeking preventive care.

Main Outcomes and Measures

The primary outcome was the frequency of insurer denials for preventive services across 5 categories: specific benefit denials, billing errors, coverage lapses, inadequate coverage, and other. Subgroup analysis was performed across patient household income, education, and race and ethnicity. Secondary outcomes included charges for denied claims, approximating patients' remaining financial responsibility for care.

Results

A total of 1 535 181 patients received 4 218 512 preventive services in 2 507 943 unique visits (mean [SD] age at visits, 54.02 [13.19] years; 1 804 637 visits for female patients [71.96%]); 585 299 patients (23.30%) had an annual household income $100 000 or higher, and 824 540 patients had some college education (32.88%). A total of 20 658 individuals (0.82%) were Asian, 139 950 (5.58%) were Hispanic, 219 646 (8.76%) were non-Hispanic Black, 1 372 223 (54.72%) were non-Hispanic White, and 25 412 (1.0%1) were other races and ethnicities not included in the other 4 groups. Of preventive claims, 1.34% (95% CI, 1.32%-1.36%) were denied, consisting mainly of specific benefit denials (0.67%; 95% CI, 0.66%-0.68%) and billing errors (0.51%; 95% CI, 0.50%-0.52%). The lowest-income patients had 43.0% higher odds of experiencing a denial than the highest-income patients (odds ratio, 1.43; 95% CI, 1.37-1.50; P < .001). The least educated enrollees had a denial rate of 1.79% (95% CI, 1.76%-1.82%) compared with 1.14% (95% CI, 1.12%-1.16%) for enrollees with college degrees. Denial rates for Asian (2.72%; 95% CI, 2.55%-2.90%), Hispanic (2.44%; 95% CI, 2.38%-2.50%), and non-Hispanic Black (2.04%; 95% CI, 1.99%-2.08%) patients were significantly higher than those for non-Hispanic White patients (1.13%; 95% CI, 1.12%-1.15%).

Conclusions and Relevance

In this cohort study of 1 535 181 patients seeking preventive care, denials of insurance claims for preventive care were disproportionately more common among at-risk patient populations. This administrative burden potentially perpetuates inequitable access to high-value health care.

Modeling Poverty and Health for Native Hawaiian and Pacific Islander and Asian Ethnic Populations

This study examined differences in poverty and health among Native Hawaiians and Pacific Islanders (NHPI) and 6 disaggregated Asian ethnic subgroups and an aggregated Other Asian category. Participants were followed longitudinally for 2 years using data from 2009 to 2019 from the Current Population Survey, a monthly survey conducted by the Census Bureau. Having 2 years of data enabled the study to assess both prevalence of poverty and fair/poor health in only 1 of the 2 years and in both years. For NHPI, 13.5% were in poverty 1of the 2 years and 7.1% in both years. Asian ethnicities showed high variability ranging from a low of 6.4% for 1 year and 1.9% for 2 years among Asian Indians to 16.0% for 1 year and 6.3% for 2 years among Vietnamese. Fair/poor health also showed ethnic variability, made most apparent after age-sex adjustment in regression models. For poverty, after adjustment, Asian Indians, Filipinos and Japanese had significantly lower odds of being in poverty at least 1 year than NHPI. For having fair/poor health, Asian Indians and Japanese experienced lower odds than NHPI for both 1 and 2 years and Filipinos for 1 year, after age/sex adjustment. The results emphasize the diversity of Asian and Pacific Islander populations, the variability of poverty over time, and the importance of using disaggregated data to understand ethnic differences in poverty and health. These findings can be used to inform future modeling of social determinants on poverty and health among NHPI and Asian subgroups.

Neighborhood gentrification, wealth, and co-ethnic density associations with acculturation stressors among Chinese immigrants

Objective

This study examined the cross-sectional relationships between neighborhood social composition and gentrification, and acculturation stressors.

Methods

Person-level data came from first-generation Chinese immigrants enrolled in the Immigrant Enclaves Study (Philadelphia, Pennsylvania, baseline 2018-2020, N = 512). A validated scale was used to assess 22 stressors associated with migration or acculturation. Neighborhood characteristics from the American Community Survey 2015-2019 and 2008-2012 included: tract proportion of foreign born Chinese, neighborhood wealth, and past decade gentrification. Most neighborhood exposures were modeled as continuous as well as binary variables (intended to represent highest level of neighborhood exposure). Multivariable negative binomial regression adjusted for age, gender, income, education, employment, language, years in the U.S., and neighborhood variables (proportion co-ethnic, and neighborhood per capita income).

Results

The majority of participants spoke Mandarin (68% vs Cantonese 32%), mean participant age was 52.7 years old, years in the US was 18, and nearly one-half of the sample had less than 8 years of education. Mean number of stressors was 5.9 with nearly 20% of participants reporting 11 or more stressors. Multivariable results found the number of acculturation stressors was 18% lower for residents in the highest co-ethnic density neighborhoods and 13% lower for residents in the highest wealth areas, compared to other areas (expβ 0.82, 95% CI [CI] 0.69, 0.98; expβ 0.87, CI 0.75, 1.01, respectively). Stressors were no different whether participants lived in gentrified areas or not.

Conclusions

Among middle-aged Chinese immigrants, acculturation stress was lower for residents in neighborhoods with higher proportion of Chinese immigrants and for residents in neighborhoods with higher wealth, whereas gentrification had no influence on acculturation stress. More work on this topic is needed with vulnerable populations such as this one, informed by local context.

Family Support and Readiness to Consider Smoking Cessation among Chinese and Vietnamese American Male Smokers

Introduction

Smoking prevalence is disproportionately high among Asian American immigrant men with limited English proficiency. Understanding the role of family support may provide insights on culturally acceptable strategies to promote smoking cessation.

Aims

This study examined how family support was associated with readiness to consider smoking cessation among Chinese and Vietnamese American male daily smokers.

Methods

We analyzed baseline data (N=340) from a cluster randomized trial of a family-based healthy lifestyle intervention. We assessed the frequency of receiving family support in various forms (encouraging use of cessation resources; praising efforts; checking-in; reminding of familial role). Multiple regression analysis was used to determine associations between family support areas and readiness to consider smoking cessation, controlling for covariates.

Results/Findings

Reporting a higher frequency of receiving praise and encouragement for one's efforts to quit was positively associated with readiness to consider cessation. Other areas of family support were not significant.

Conclusions

These findings provide evidence to explore specific areas of family support in enhancing Asian American smokers' readiness to consider cessation. As there is high interest from Asian American family members to support their smokers for quitting, culturally specific and acceptable strategies are needed to promote smoking cessation among Asian Americans.