Sub-Ethnic and Geographic Variations in out-of-Pocket Premiums for Private Health Insurance Among Near-Retirement Aged Asian Americans: Multilevel Modeling

Purpose: With the implementation of the Affordable Care Act, it becomes more important to understand private health insurance status and the financial burden among pre-retirement aged individuals who are not yet covered by Medicare. The current study examined this topic by comparing six sub-ethnic groups of Asian Americans, whose heterogeneity is often overlooked with the aggregated data that represent the whole Asian group. In addition, this study examined and controlled for geographic variations, which have not been studied with these populations. State- and county-level variations in private insurance premiums have been reported due to the differences in insurer competition, negotiation between insurers and healthcare providers, degree of risk pooling, and cost of living depending on where the person lives.

Methods: The 2007-2011 National Health Interview Survey were analyzed for 4,628 Asian Americans (ages 50-64), including 697 Asian Indian, 1,125 Chinese, 1,393 Filipino, 434 Japanese, 524 Korean, and 455 Vietnamese individuals. Non-Hispanic Whites were included as a comparison group (n=19,236). The STATA SVY procedures were used to account for the complex sampling design in describing private insurance status and out-of-pocket (OOP) premiums by race/sub-ethnicity. Three-level multilevel modeling (state>county>individual) was conducted using STATA. The participants were nested within 780 counties from 51 states.   

Results: Bivariate results indicate that overall, 67.9% of pre-retirement aged Asian Americans had private health insurance, while the rates varied from 55.4% among Koreans to 83.8% among Japanese. Among non-Hispanic Whites, 78.4% had private insurance. Among those with private insurance, 8.6% of Asians and 7.3% of non-Hispanic Whites purchased their coverage in the individual health insurance market, not through their employment. However, the rates also varied from 4.0% among Filipinos to 21.5% among Koreans. In terms of the annual OOP premiums, while Asian Americans ($4,093, in 2011 dollars) and non-Hispanic Whites ($4,058) with private insurance paid similar amounts, there were significant subgroup differences (from $3,253 among Vietnamese to $4,876 among Asian Indians).

When geographic variations in OOP premiums were examined, the results found only modest variation across states (1.2% of the variance) and counties (3.5%), while most of the variation was observed between individuals (95.9%). However, even with this low degree of clustering, the three-level model significantly improved the model fit compared to the single-level model and each of the two-level models (i.e., individuals<counties or individuals<states). Moreover, when the three-level unconditional model was conducted only among Asians, 13.6% of the variance in OOP premiums was explained by county/state-level differences, indicating the importance of accounting for geographic variations.  

The final three-level conditional model indicates that compared with their non-Hispanic White counterparts, Filipinos and Vietnamese paid significantly less to access private health insurance (p<.001, respectively). Among other covariates, older ages, being married, higher educational levels, non-employment based private insurance, and high deductibles were associated with greater OOP premiums. However, functional status and self-rated health status were not significant.    

Implications: This study demonstrates the importance of examining within-group heterogeneity among Asian Americans and the importance of considering geographic variations in understanding their access to and the burden of private health insurance coverage.