Health Insurance for Asian Americans, Native Hawaiians, and Pacific Islanders Under the Affordable Care Act

Since passage of the 2010 Affordable Care Act (ACA), more than 20 million Americans have gained health insurance.¹ While previous analyses have documented coverage gains for most major racial/ethnic populations, virtually no attention has been focused on Asian Americans, Native Hawaiians, and Pacific Islanders (AANHPIs).² The fastest growing US racial/ethnic group,³ AANHPIs comprise an extraordinarily heterogeneous group of people. They represent more than 50 ethnicities and speak 100 languages. We analyzed (1) the extent of post-ACA health insurance coverage gains for AANHPIs; and (2) whether disparities in coverage—both between AANHPIs and other major groups, as well as within major AANHPI subgroups—have narrowed over time.

The American Community Survey (ACS)—the nation’s largest household survey—collects data on health insurance, race/ethnicity, and other demographic information from questionnaires sent to around 295 000 households monthly, with an approximate response rate of 95%. We calculated changes in the uninsured rate among adults (ages 18-64 years) in the period before the ACA’s major coverage expansions (2009-2013) and after (2015-2016) for AANHPIs and compared them with rates for non-Hispanic whites, non-Hispanic blacks, and Hispanics. We excluded 2014 as a transition year. We also measured such changes for the 7 major Asian American subgroups (Asian Indian, Chinese, Filipino, Vietnamese, Korean, Japanese, and other Asian) and 4 major Native Hawaiian and Pacific Islander (NHPI) subgroups (Native Hawaiian, Samoan, Guamanian or Chamorro, and other NHPI). The study used publicly available data and was deemed non–human subjects research by the Harvard School of Public Health institutional review board.

In addition to unadjusted estimates, we used linear regression models to estimate the adjusted change in coverage, controlling for citizenship status, self-employment, education, marital status, sex, English-speaking ability, nativity, income-poverty ratio, income, age, state, and state-year unemployment rate. All analyses used ACS survey weights.

Following the ACA, significant reductions in uninsurance were achieved for all major racial groups (Table and Figure). Notably, the gap between whites and nonwhites shrank for all major groups, although only for AANHPIs did the disparity with whites disappear entirely after passage of the ACA.

Reductions in uninsurance occurred for all 11 AANHPI subgroups, ranging from −14.3 percentage points in the Guamanian or Chamorro subgroup (95% CI, −22.4 to −6.2) to −4.1 in the Japanese subgroup (95% CI, −5.8 to −2.5), although nonsignificantly for Native Hawaiian, Samoan, and other NHPI. For Asian Americans, while the highest (Korean) and lowest (Japanese) uninsured subgroups retained their relative positions, the uninsured gap between them narrowed substantially (20.6 percentage points pre-ACA to 8.1 points post-ACA). For NHPI subgroups, the uninsured gap between the highest and lowest subgroups was substantially unchanged (10.0% to 9.6%).

Our findings document AANHPI coverage gains that essentially eliminated pre-ACA coverage disparities relative to whites. Within AANHPI subgroups, disparities have narrowed appreciably, especially for Asian American subgroups. The smaller sample sizes of NHPI subgroups may explain why some subgroup coverage changes were not statistically significant.

We are not able to attribute causality to these findings, but the 2014 launch of the ACA’s marketplaces and Medicaid expansion in participating states likely was the major factor. Study limitations include only 2 years of post-ACA data, absence of health care utilization data, and imprecise measurement of insurance and income in the ACS. To our knowledge, this report is the first to detail gains in AANHPI health insurance coverage since implementation of the ACA through the end of Barack Obama’s presidency. Future research should explore whether these gains in coverage persist and the long-run effects of these changes on health care disparities.

Accepted for Publication: March 4, 2018.

Published Online: April 30, 2018. doi:10.1001/jamainternmed.2018.1476

Correction: This article was corrected on February 17, 2020, to fix wording errors in the Methods section in a survey description.

Corresponding Author: John J. Park, MBChB, MPH, Harvard T. H. Chan School of Public Health, 677 Huntington Ave, Boston, MA 02115 (john.park@mail.harvard.edu).

Author Contributions: Dr Sommers had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Park, Colditz, Koh.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Park, Humble, Koh.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Humble, Sommers, Colditz, Koh.

Administrative, technical, or material support: Park, Colditz.

Conflict of Interest Disclosures: None reported.