Research - Sandhu et al.

COVERED CALIFORNIA AWARENESS IN THE MIDDLE EASTERN AND SOUTH ASIAN COMMUNITY

Manjot Sandhu, BS*; Hammad Khan, MPH*; Suhail Zeb, BS; Pranaya Venkatapuram, BS; Shagufta Yasmeen, MD.

*Authors contributed equally to this work.

ABSTRACT

Importance: With minorities being historically more likely to be uninsured, research shows that the success of recent health insurance reform initiatives such as Covered California will be at least partly dependent on these programs’ ability to reach minority populations.

Objective: To examine the awareness, perceptions, and understanding of Covered California among the Middle Eastern & South Asian community. Additionally, differences based on age, education, reading language, and gender were also investigated.

Methods: Convenience sampling was used to survey Middle Eastern adults ages 18 through 69 from August 2014 to October 2014 in the Greater Sacramento region. Knowledge of plans, name recognition ability, awareness of eligibility, opinion of pricing, and perception of monetary worthiness were assessed through a questionnaire.

Results: 189 completed questionnaires were analyzed; the median age of respondents was 38.3 ± 12.9 yrs. 55% recognized ‘Obamacare’ as an identifiable name while ‘Affordable Care Act’ and ‘Covered California’ were both significantly less recognized. 79.4% of respondents believed they were eligible for Covered California coverage. 15% reported understanding the differences between the Bronze, Silver, Gold, and Platinum plans. 70% reported that they did not believe that the rates provided for representative Covered California plans were fairly priced.

Conclusion: Significant lack of understanding regarding Affordable Care Act implementation exists within the Middle Eastern and South Asian population with several impediments to Covered California accessibility being displayed namely lack of awareness, understanding, and perceived equitability of health insurance plans.

INTRODUCTION

Despite the Asian-American population expected to grow by 213% by 20501, research exploring the disaggregated health needs of the diverse Asian American community is sparse; research exploring Asian American sub-populations such as the Middle Eastern and South Asian communities is especially rare. And with the implementation of recent health reform legislation designed specifically to target uninsured populations – among them Asian American populations that have historically experienced higher rates of being uninsured than the national average2 — assessing the impact and effectiveness of the Patient Protection and Affordable Care Act (ACA) amongst such Asian subpopulations is necessary.

In California, one of the ACA’s most significant effects is the establishment of Covered California, California’s unique health insurance exchange marketplace. However, the complexity of the ACA and these newly established systems has led to significant amounts of skepticism regarding eligibility3 as well as a significant amount of uninformed concern regarding the actual benefits of ACA implementation4. Additionally, research has repeatedly shown that poorer familiarity with insurance options as a whole can lead to delays in seeking care and have significant negative overall effects on health outcomes5-7.

In this study, the Middle Eastern and South Asian community in the Greater Sacramento region is used as a model to explore the level of familiarity and understanding regarding health insurance after the completion of one full enrollment cycle of Covered California. This exploration centers around the ability to parse through an often confusing amalgamation of terminology, perceptions regarding eligibility, and opinions regarding equitability of Covered California plans. The objective was to establish a baseline record to explore the need for additional education and potential intervention and in that end data regarding age, gender, language, and education level was also explored.

RESULTS

Between August 2014 and October 2014, 189 participants completed the questionnaire. The median age of participants was 38.3 ± 12.9 years with 76.7% males (n = 145) and 44% females (n = 44). 30.6% (n = 58) of the sample reported having less than a high school education, 21.1% (n = 40) reported having up to a high school education, and 48.1% (n = 91) reported having at least a college education. 70.8% (n = 134) reported English being their current primary reading language with remaining participants reporting Other; Urdu was specifically written in by 2.1% (n = 4) and Hindko by 1.1% (n = 2), with the rest electing not to specify.

Overall, Table 2 shows that based on this sample respondents reported that 79.4% ( n = 150) believed they were eligible. 18.5% (n = 35) believed they understood the differences within the metal tier system. 34.4% (n = 65) believed they could afford monthly insurance rates while 21.5% (n = 14) of those 65 were willing to pay. And 36% (n = 68) reported feeling that plans provided by Covered California were worth the price. This data was further analyzed based on stratification of age groups, genders, and primary reading language as shown in Table 3.

Knowledge

When determining the knowledge the participants had in knowing the terms listed, 85% reported recognizing the term “Obamacare,” 37.5% reported recognizing the term “Covered California,” and 22.7% recognized the term “Affordable Care Act.”

When determining the various combinations of terms the participants knew, 15.3% had heard of all three terms: Affordable Care Act, Obamacare, and Covered California. 14.8% has heard of “Obamacare” and “Covered California.” 6.9% has heard of the “Affordable Care Act” and “Obamacare.”

Exclusively, 55% reported only recognizing the term “Obamacare.” 7.4% reported only recognizing the term “Covered California.” And, 0.5% reported only having heard of the Affordable Care Act.

When asked who they had heard these terms from, 51.9% (n = 98) reported first hearing about Covered California from a family member. The remaining sources of knowledge were friends (28.6%, n = 54), physicians (5.8%, n = 11), and calls from local offices (2.1%, n = 4).

Eligibility

When asked whether they believed they were eligible for Covered California plans, 79.4% (n = 150) believed themselves to be eligible for these plans (Table 2). Stratified over age, beliefs regarding eligibility are as follows: 83.3% of the 18-20 age group, 86% of the 21-30 age group, 71.1% of the 31-40 age group, 56.5% of the 41-50 age groups, 84% of the 51-60 age group, and 72.7% of the 61-70 age group. Upon regression analysis, a significant effect was found when looking at age (p = .003) in regards to knowledge about eligibility. As the age of the participant increased, the likelihood of that participant believing that they are eligible decreased by 0.045.

Comparing across education levels, 60.6% of participants who had some form of college education believed that they are eligible. Of participants who attended high school, 85.0% believed that they are eligible. Of those with less than a high school education, 79.3% believed that they are eligible.This effect of education of the participants’ beliefs regarding eligibility was also found to be significant. Having less than a college education increased one’s chances of believing her or she was eligible for Covered California. (OR= 1.147, p=.032).

Comparing across reading languages, 67.2% of English readers stated that they believed that they are eligible while 80.3% who reported “Other” languages believed themselves to be eligible. These differences were not found to be significant.

Plan Difference

When asked if they understood the differences between bronze, silver, gold, and platinum insurance tiers, only 18.5% (n = 35) reported knowing the difference (Table 2). Stratified across age groups, those who reported not knowing the differences between plans were as follows: 91.7% of the 18-20 age group, 71.9% of the 21-30 age group, 76.3% of the 31-40 age group, 89.1% of the 41-50 age group, 80.0% of the 51-60 age group, and 81.8% of the 61-70 age group. These differences were not found to be statistically significant.

Across different levels of education, of participants who stated that they had a college education, 85.1% reported not knowing the differences. 82.5% of those with only a high school education were unaware of the differences. And 100% of those with less than a high school education Those that stated they had less than a high school education were 100% (n = 58) likely to be unaware of the different packages available.

When looking at the reading languages of the participants, of those that stated English as their primary reading language 87.3% reported being unaware of the differences between tiers while only 68.9% of those that stated “other” did. And 100% of those who stated no reading language (n = 8) were unaware.

Affordability & Worth

When asked if they were able to afford the rates listed for a Covered California plan representative for Sacramento County, 34.4% (n = 65) participants of the total sample reported being able to afford to pay for one of the listed plans. Furthermore, when asked if they believed the plan was worth the cost 35% (n = 68) believed that it was (Table 2).

Stratified across age, those who found the plan was worth the cost were as follows: 25.0% of the 18-20 age group, 28.1% of the 21-30 age group, 50% of the 31-40 age group, 37% of the 41-50 age group, 40% of the 51-60 age group, 36.4% of the 61-70 age group. Across levels of education, 34.0% participants with college educations believed the plans were worth the cost while the same was true of 37.5% of those with only a high school education and 24.1% of the hose with less than a high school education. Across reading levels, 33.6% of those who reported English as their primary reading language believed the plans were worth their price while 36.1% who reported “other” believed they were. On analyses, these differences were not found to be statistically significant.

DISCUSSION

When analyzing the data pooled from the survey as a whole, several conclusions can be drawn. On simply the level of recognition, a clear disparity can be seen with the term “Obamacare” being recognized at a rate (85.0%) more than double the rates of “Covered California” (37.5%) or “A ordable Care Act” (22.7%). With Covered California being the in-state health exchange designed to provide Californians with a health insurance marketplace, the lack of name recognition is troubling and indicates a clear gap

in awareness within the Middle Eastern and South Asian community that needs to be addressed.

In addition to issues with awareness and recognition, the data also suggested a clear de cit in knowledge base in regards to the structure of Covered California’s health insurance marketplace. With only a mere 18.5% (Table 2) knowing the di erence between the bronze, silver, gold, and platinum plans o ered by the insurance providers in their county, the Middle Eastern and South Asian community clearly lacks even a basic understanding of vital di erences between plan tiers. With di erent tiers carrying di erent services at di erent monthly rates, a lack of understanding can have signi cant nancial outcomes as well as be a potential risk to health outcomes.

When looking further into the nances, yet another de ciency is apparent; 65.6% of the total sample (n=189) feel as though they cannot a ord to pay for a Covered California health care plan in their county. Of the 34.4% of the total sample that can a ord a healthcare plan in their county, only 21.5% are willing to pay for a plan. e majority (78.5%) is not willing to pay for a plan, even if they can a ord one (Table 2). When asked to select a Covered California plan that they could a ord, only 36% (Table 2) of individuals participating in the survey felt as though the plan they selected was worth the money. ese nancial gures bring up two salient points: First, whether eligible or not, the nancial burden of paying for health insurance is considered too high in this population. Second, a negative perception appears to exist in regards to the actual value of having a health care plan to begin with. Reasons as to why these viewpoints exist within the Middle Eastern and South Asian population requires further investigation.

e question now is how to rectify these drastic gaps in awareness, knowledge, and negative perception about Covered California health plans. Possible solutions include, but are not limited to, lobbying for state funding to develop culturally conscious marketing, developing educational interventions for local area community centers, and training select members of the community to relay information on a local level. Remarkably, the overwhelming majority of this population received their knowledge about Covered California from either friends or family members, with doctors, news and television, and local o cials being among the least cited sources of info. us, the sources with the most accurate and detailed information (doctors, news and television, and local o cials) are reaching this population the least. Since the primary source of knowledge is coming from friends and family, the training of local community leaders, and potentially clergy, may prove to be highly beneficial.

Strengths of this study include a large sample size and the investigation of communities often overlooked within the medical literature. e underrepresentation of females relative to males (1:3) within the sample was a major weakness.

In terms of further areas of research, these ndings showcase the growing need for the study of critical subpopulation groups in the Sacramento area. With the implementation of the Patient Protection and A ordable Care Act well under way, the role that Covered California plays in providing for California’s minority communities is critical. As we have shown here, the Middle Eastern and South Asian community faces signi cant challenges in access to health insurance.It is our reccomendation that future research focus on elucidating the factors behind the knowledge gaps presented in this study, speci cally in relation to the metal tiers system as highlighted previously. In addition, it is likely that these challenges also exist in parallel across various other understudied demographics. Conducting studies similar to our own within these groups would prove bene cial in order to ascertain the similarities and di erences.

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