Archive - Report

 

ASIAN AND PACIFIC ISLANDER CAUCUS

TASK FORCE ON MULTICULTURAL HEALTH

CALIFORNIA DEPARTMENT OF HEALTH SERVICES

October 2000

Asian and Pacific Islander Caucus Members
Ignatius Bau, J.D., Asian and Pacific Islander American Health Forum, San Francisco
Teresita Bautista, Alameda County Medical Center, Oakland
Chi Kue, Hmong American Women's Association, Fresno
Miya Iwataki, Los Angeles County Department of Health Services Office of Diversity and
Asian Pacific Planning and Policy Council, Los Angeles
Lola Sablan-Santos, Guam Communications Network, Santa Monica
Winston Wong, M.D., Region IX, Health Resources and Services Administration,
Department of Health and Human Services, San Francisco

Written by Ignatius Bau. Supported in part by The California Endowment through the Asian and Pacific Islander American Health Forum's Asian American and Pacific Islander Health Improvement Project.

Background

The California Department of Health Services (DHS) Task Force on Multicultural Health (TFMH) was established in 1993 as an advisory body to the Director of DHS. It is staffed by the Office of Multicultural Health (OMH), which was established by Executive Order W-58-93. In 1999, legislation was enacted to establish the OMH as a permanent office within DHS (AB 1107).

The mission of the TFMH is to improve the health, well-being and quality of life of the multi-ethnic communities of California. Given its shared accountability to California's multi-ethnic communities, the TFMH is committed to:

Assist the Department of Health Services in its charge to develop, implement and monitor culturally sensitive, responsive policies and quality, equitable and culturally competent programs and services;

Serve as a conduit for an interactive and collaborative exchange of information and resources within and between these communities and the Department of Health Services; and

Participate as an active partner to proactively identify and advise the Department of Health Services on health issues pertinent to multi-ethnic communities.

(Revised July 1998)

Currently, there are 24 members of the TFMH, with 6 Asian and Pacific Islander (API) members. The TFMH meets quarterly, with members serving two-year terms. The API Caucus conducts monthly conference calls. An Asian/Pacific Islander (currently Miya Iwataki) also represents the API Caucus on the TFMH Steering Committee.

Past Asian and Pacific Islander members of the TFMH include:

Asian and Pacific Islander Health Advocacy in California in the 1990's

During the past decade, there have been significant milestones in advocacy for the health of Asians and Pacific Islanders in the state of California. Although there have been significant health advocacy activities at the local county and city levels throughout the decade, this overview focuses on statewide advocacy efforts. The overview also highlights those conferences, hearings and reports in which specific policy recommendations were developed as an outcome. It is important to place the findings and recommendations of this Asian and Pacific Islander Caucus into the historical context of these advocacy efforts.

California's Asians and Pacific Islanders in 1990

From 1980 to 1990, the Asian and Pacific Islander population in California increased 117% to 2,845,659 persons, growing from 5.5% to 9.6% of the total state population. The increase was even greater for some Asian and Pacific Islander populations: an increase of 229% for Vietnamese, 236% for Tongans, 386% for Laotians, 1,121% for Cambodians and 6,297% for Hmong living in California. In 1990, 39% of the Asian and Pacific Islanders in the U.S. resided in California.

San Francisco County had the greatest percentage of Asians and Pacific Islanders as part of its total county population (29.1%), followed by Santa Clara County (17.5%), San Mateo County (16.8%), Alameda County (15.1%), San Joaquin County (12.4%) and Los Angeles County (10.8%). However, Los Angeles County had the greatest number of Asian and Pacific Islander residents (8.863 million), followed by San Diego County (2.498 million) and Orange County (2.410 million).

1990 California Commission on Economic Development Hearing on Asian Health Issues

In April 1990, the California Commission on Economic Development, chaired by California Lieutenant Governor Leo McCarthy, conducted a hearing on Asian and Pacific Islander health issues. The Asian Pacific Islander Health Coalition of Alameda County organized the testimony for the hearing in Oakland, which was attended by other local and state government officials. The hearing was organized into panels of presenters which provided an Overview and then discussed Health Access, Health Problems, and Solutions and Recommendations.

Among the data highlighted at the hearing was the fact that the tuberculosis rate for Asians is five times the national average, that Asians are getting AIDS much faster than any other ethnic group, that lung cancer incidence among Chinese and Hawaiian women is among the highest in the world, that Asians are six times more likely than the general population to be chronic carriers of Hepatitis B, that hypertension is alarmingly high among Filipinos, and that the mental health needs of Southeast Asian refugees are hardly being met.

Among the recommendations for state government were:

Among the recommendations for local government were:

An Asian and Pacific Islander Task Force was active in the planning and implementation of the June 1991 "Unity in Health, Diversity in Culture" Conference sponsored by the California DHS Health Promotion Section. The conference was convened to provide input into California's implementation of Healthy People 2000 objectives and to develop a Multi-Ethnic Health Promotion Agenda for California.

In May 1992, the findings and recommendations of the Asian and Pacific Islander Task Force were published in a final report. The report included detailed discussions of Cancer, Diabetes, Heart Disease and Stroke, Nutrition and Tobacco, topics that had been prioritized by the Asian and Pacific Islander Task Force, with input from 88 health, social, and human service organizations, ethnic organizations and individuals from government and academic institutions prior to the conference and 100 participants at the conference.

Cancer

Cancer is the second leading cause of death among Asians and Pacific Islanders in California, accounting for one of every four Asian and Pacific Islander deaths in the state. In 1991, cancer data was only available from the national Surveillance, Epidemiology and End Results (SEER) dataset for Chinese, Japanese, Filipinos and Hawaiians. Since 1988, SEER began collecting cancer data for Vietnamese, Lao, Kampucheans, Hmong, Koreans and Asian Indians/Pakistanis.

California's Tumor registry also had collected data for specific Asian and Pacific Islander subpopulations since 1988 but that data was not yet available for analysis in 1991.

Among the recommendations from the Asian and Pacific Islander Task Force related to cancer were recommendations for increased education and programs about tobacco and Hepatitis B and recruitment and training of Asian and Pacific Islander women to provide cervical and breast cancer education and screening.

Diabetes

The proportional mortality of Asians and Pacific Islanders in California from diabetes is one and a half times greater than that of whites. The impact of diabetes is particularly acute among Samoans, Guamanians, Hawaiians and Japanese residing in California.

Among the recommendations from the Asian and Pacific Islander Task Force related to diabetes were increasing culturally relevant education and screening among at risk Asian and Pacific Islander populations. The Task Force also recommend working with organizations such as the American Diabetes Association to fund models of diabetes detection and management that are effective in the Asian and Pacific Islander communities and to research the nutrient composition and dietary management of ethnic foods.

Heart Disease and Stroke

Heart disease and stroke are the leading causes of death among Asians and Pacific Islanders in California, accounting for four of every ten deaths among Asians and Pacific Islanders. The Asian and Pacific Islander Task Force recommended increased tobacco use prevention, high blood pressure and cholesterol detection and control, more studies about diet and acculturation, and improved surveillance.

Nutrition

While traditional Asian and Pacific Islander diets may be lower in fat and higher in fiber, Asian and Pacific Islander immigrants to the U.S. may experience an increase incidence of cancer and heart disease with an increase in dietary fat. Other components of the Asian diet, especially excess intake of sodium from salt-cured and pickled foods, may be related to increased hypertension and gastric cancers. Under nutrition, especially low calcium and low iron intake, is a concern among immigrant and refugee Asians and Pacific Islanders, especially women, infants and children.

The Asian and Pacific Islander Task Force made recommendations about including culturally acceptable foods in government food supplement programs, bilingual food labeling for imported foods and working with Asian and Pacific Islander restaurants to provide low-fat and low-sodium choices to consumers.

Tobacco

There is a high prevalence of smoking among Asians and Pacific Islanders, especially among men and among immigrants. For example, studies of Southeast Asian refugees in California reported smoking rates of 55-65% for Vietnamese men, 71% for Cambodian men and 92 for Lao men. There also is concern about the aggressive marketing practices of U.S. tobacco companies in Asia.

The Asian and Pacific Islander Task Force recommended improved surveillance, integration of Asian and Pacific Islander families, workplaces, schools and communities with health educators and health care providers in tobacco use prevention interventions and smoking cessation programs, development of culturally appropriate and linguistically accessible educational materials and programs, establishment and enforcement of local ordinances prohibiting smoking in restaurants and businesses and prohibitions on U.S. government promotion of American tobacco products in international markets.

Overall Recommendations

The Asian and Pacific Islander Task Force noted that other fundamental issues such as inequitable health care access, infectious disease control and trauma prevention also had a significant impact on Asian and Pacific Islander health but could not be addressed due to time and resource limitations. However, there was consensus on the following overall recommendations:

Community Interventions

Seek funding in order to develop culturally, linguistically, literacy appropriate interventions.

Promote health through ethnic media.

Develop a centralized clearinghouse as part of an Office of Minority Health Affairs to house and disseminate intervention and educational materials, health status data and an human resources experts referral list.

Resource Development

Develop partnerships with the University of California, California State Universities, and national voluntary associations (e.g. American Health Association, American Lung Association, American Cancer Society, American Diabetes Association, etc.).

Work with professional organizations (e.g. California Medical Association, California Association of Family Practitioners, California Diabetes Association, California Nurses Association, etc.).

Expand this Asian and Pacific Islander Task Force to serve as a statewide coalition to advance the health concerns of California's Asian and Pacific Islander population.

Policy

Increase data collection among Asians and Pacific Islanders.

Develop appropriate environmental interventions (e.g. ordinances, merchant education, etc.).

1992 California Asian Pacific Islander Health and Human Services Network Legislative Day

Asian and Pacific Islander health and human service organizations throughout California gathered together for the first time in Sacramento in 1992 to educate legislators and administrative officials about the needs of Asian and Pacific Islander communities and to engage in advocacy for increased funding and programmatic attention to our populations. Organizing efforts for this first legislative day were led by the Asian Pacific Planning Council in Los Angeles and the Asian American Health Forum in San Francisco.

1993 California Asian Pacific Islander Health and Human Services Network Legislative Day

After a second year of working together on common health and human service issues on behalf of Asian and Pacific Islander communities, work began to formalize the network, evolving into the founding of the Asian and Pacific Islander California Action Network (APIsCAN) in 1994.

1994 Analysis of the Health Indicators for California's Minority Populations

In 1994, the California Department of Health Services published an analysis of health data for California's minority populations collected in 1990. This was the most comprehensive health data published to date on California's Asian and Pacific Islander populations, including vital statistics data on the following Asian and Pacific Islander subgroups: Chinese, Japanese, Korean, Vietnamese, Cambodian, Thai, Laotian, Filipino, Asian Indian, Other Asian, Hawaiian, Guamanian, Samoan and Other Pacific Islander. The report also included a useful discussion of the collection, coding and analysis of health data by race and ethnicity.

Natality Indicators

The percentage of births to mothers under age 18 for Laotians (8.7%) was the highest among all racial/ethnic populations in the state. The percentage of low birth weight infants for Asian Indians (8.4%), Guamanians (8.0%), Thai (7.5%) and Cambodian (7.1%) were among the highest in California. On the other hand, the percentage of mothers with early prenatal care was lowest for Samoans (45.7%) and Laotians (56.1%).

Mortality Indicators

Samoans (1,088.7 per 100,000), Other Pacific Islanders (819.5 per 100,000) and Laotians (732.2 per 100,000) had some of the highest age-adjusted death rates among all racial/ethnic populations in California. Other Pacific Islanders (275.7 per 100,000), Guamanians (243.8 per 100,000) and Samoans (193.7 per 100,000) and Asian Indians (103.5 per 100,000) had some of the highest age-adjusted death rates for coronary heart disease. Similarly, Samoans (137.6 per 100,000) and Cambodians (106.8 per 100,000) had the highest age-adjusted death rate for stroke in the state. Other Pacific Islanders (71.1 per 100,000) and Laotians (52.9 per 100,000) had the highest age-adjusted death rates from unintentional injuries. Cambodians (20.9 per 100,000), Pacific Islanders as a group (13.6 per 100,000) and Vietnamese (11.6 per 100,000) had much higher age-adjusted homicide rates than other Asian populations (5.1 per 100,000 for Asians as a group).

Morbidity Indicators

Asians and Pacific Islanders had the highest incidence rate for tuberculosis (53.3 per 100,000) among all racial/ethnic populations in California.

1994 Asian and Pacific Islander California Action Network Inaugural Legislative Conference

With partial support from the Pacific Telesis Foundation and the California Consumer Protection Foundation, the Asian and Pacific Islander American Health Forum and the Asian Pacific Planning Council led the efforts to convene a two-day statewide legislative conference in April 1994. The Asian and Pacific Islander California Action Network (APIsCAN) was formed with the following mission statement: "to improve the quality of life of Californians through the building of linkages among Asian and Pacific Islander coalitions and representative bodies; and support efforts that promote the interest of Asian and Pacific Islander communities." An organizational structure was adopted, based on a coalition of 18 local and regional Asian and Pacific Islander health and human service organizational networks throughout California. There was a commitment to convene at least once annually in Sacramento and engage in both education and advocacy on health and human service issues impacting California's Asian and Pacific Islander communities. Participants also made nearly twenty visits to legislative and executive branch offices on issues of health care reform, health data collection, welfare reform and implementation of Medicaid managed care.

1995 Asian and Pacific Islander California Action Network 2nd Annual Conference and Legislative Day

At the 2nd APIsCAN conference, policy positions and recommendations were developed for the conference participants on managed care, mental health, welfare reform, affirmative action, immigration policies, block grants and alcohol and drugs. Legislative leaders participated in a legislative forum and representatives from health and social service departments and agencies participated in an administrative town hall meeting at the conference. Finally, conference participants made visits to 25 legislators. The mission statement of APIsCAN was changed to: "APIsCAN is a catalyst for public policy and community development that promotes health, social, economic and political equity for the diverse Asian and Pacific Islander communities through organizing, collaboration, leadership development and education."

1995 "The Health and Well-Being of Asian and Pacific Islander American Women"

Asians and Pacific Islanders for Reproductive Health issued "The Health and Well-Being of Asian and Pacific Islander American Women," a report on based on over a year of community forums, focus groups and roundtable discussions involving approximately 200 Asian and Pacific Islander women and a statewide conference on the health issues and needs of Asian and Pacific Islander women in California with 155 participants.

The report found:

Among the recommendations from the community research and conference were more information to raise the health consciousness of Asian and Pacific Islander American women, more reproductive health programs and services for Asian and Pacific Islander American women, services and resources to assist with the social and cultural adjustment of living in the United States, educational and vocational resources for Asian and Pacific Islander American women, support for Asian and Pacific Islander American families and communities, and resources to address domestic violence against Asian and Pacific Islander American women and children.

1996 Asian and Pacific Islander California Action Network 3rd Annual Legislative Conference

The third APIsCAN conference highlighted issues of managed care, federal block grants, substance abuse and mental health services, welfare reform, immigrant rights, affirmative action, and education. Extensive policy positions and recommendations on each of these issues were prepared for the conference participants. Conference participants also rallied on the steps of the Capitol to demonstrate the visible presence of Asians and Pacific Islanders visiting the Legislature. Half a dozen legislative leaders attended the legislative forum at the conference and nearly thirty legislative visits were made during the conference. Representatives from health and social service departments and agencies addressed the conference on the second day of the two-day conference and then met for more extensive discussions with APIsCAN leaders the day after the conference.

1997 "The Health Status of Asian and Pacific Islander Americans in California"

The Asian and Pacific Islander American Health Forum (APIAHF) was commissioned by The California Endowment and the California HealthCare Foundation to write the report, "The Health Status of Asian and Pacific Islander Americans in California." The report included chapters on Asian and Pacific Islander population demographics, health issues, barriers in accessing quality care, enabling community dynamics and public policy recommendations.

The report noted data from 1989-1991 showing the following ten leading causes of death for Asians and Pacific Islanders in California: heart disease, cancer, cerebrovascular disease, unintentional injuries, pneumonia/influenza, chronic obstructive pulmonary disease, diabetes, suicide, homicide and congenital anomalies. The report also reviewed data regarding California's Asians and Pacific Islanders on reportable diseases, mental health, oral health, child and adolescent health, women's health, elderly health, gay/lesbian, bisexual and transgender health, environmental health and occupational health. Unfortunately, there was little new data on Asian and Pacific Islander subpopulations besides the 1990 data contained in the 1994 DHS report.

In terms of health care utilization, the top five diagnosis-related groups for California hospitalizations for Asians and Pacific Islanders (and "others") in 1992 were vaginal delivery without complicating diagnosis, normal newborns, neonate with other significant problems, Cesarean section and psychoses. In 1993, Asians and Pacific Islanders (and "others") averaged 428 days hospitalized per 1,000 persons each year, compared to 614 days for the general California population. Average length of hospitalization also was lower, 3.58 days, compared to 4.41 days for whites. On the other hand, Asians and Pacific Islanders (and "others") admitted from emergency rooms had longer average hospitalizations (5.69 days) compared to whites (5.51 days). In 1993, 43% of California's Asian and Pacific Islander hospitalizations were covered by private health insurance, 33% by Medicaid and 15% by Medicare.

The report also reviewed some of the structural and systems barriers to health facing Asians and Pacific Islanders: inadequate culturally and linguistically sensitive services, inadequate staff development for cultural competence, inadequate data collection systems, inadequate knowledge, research and ethnic-specific methodologies, anti-immigrant legislation and environment, and inadequate health professional recruitment strategies and policies. On the other hand, Asian and Pacific Islander communities have several enabling dynamics that can facilitate and promote health: geographic clustering, extensive ethnic-specific networks, communities strongly influenced by local and national leaders, emphasis on extended family, international relationships and coalescence of national health leadership.

Among the report's numerous recommendations:

1997 Asian and Pacific Islander California Action Network 4th Annual Legislative Conference

After the passage of the federal welfare and immigration laws in 1996, the 4th APIsCAN conference focused primarily on California's implementation on these critical federal legislative changes. With the theme of "devolution" of authority from Congress to the states under the welfare law, these policies took on heightened importance. Both legislative and administrative forums were held, with extensive dialogue about the pending proposals for the implementation of the federal welfare law and the creation of state-funded safety net programs for those disqualified for federal programs, especially immigrants. Other important policies on health care, mental health, substance abuse, managed care, federal block grants, affirmative action also were included on the conference agenda. These issues were thoroughly discussed in the policy position papers prepared for the conference, with detailed policy, service delivery, research, education and training, and leadership recommendations. The 1997 conference also included significant participation by Asian and Pacific Islander youth.

1998 Asian and Pacific Islander California Action Network 5th Annual Legislative Conference

In 1998, the APIsCAN conference continued to focus on issues of welfare reform, managed care, substance abuse, and the implementation of the new Children's Health Insurance Program, named Healthy Families in California. Issues of bilingual education also were discussed, with Proposition 227 on the ballot. There again was significant participation by Asian and Pacific Islander youth at the conference, with a parallel youth track. An advocacy training was added to the conference and the administrative forum was changed to roundtable discussions with key administrative officials. Conference participants joined a Capitol rally focusing on the adverse impact of welfare reform on immigrants. A legislative forum was held and legislative visits also were made.

1999 Asian and Pacific Islander California Action Network 6th Annual Legislative Conference

For the nearly 120 participants at the 1999 APIsCAN conference, the issues of welfare reform, health, mental health, substance abuse, immigrant rights and youth were again highlighted. Conference participants participated in a rally on welfare issues on the steps of the Capitol and then fifteen teams prepared for over thirty legislative visits the following day.

These statewide efforts throughout California during the past decade form the foundation for the findings and recommendations of the task Force on Multicultural Health's Asian and Pacific Islander Caucus in this report.

California's Asians and Pacific Islanders Today

Asians and Pacific Islanders in California continue to be the fastest growing community of color in the state. According to the U.S. Census Bureau, the Asian and Pacific Islander population in California grew to 3,937,722 persons as of July 1998, a 33.6% increase from 1990. Asians and Pacific Islanders are now 12.1% of the California state population. The Census Bureau estimates that the Asian and Pacific Islander population in California will increase to 4.2 million persons by the year 2000 and over 9 million persons by the year 2025.

This population growth is even more evident in certain local areas. For example, the Asian and Pacific Islander population in Contra Costa County increased 49.7% from 1990 to 1998, with Asians and Pacific Islanders now 12.8% of the county population and the Asian and Pacific Islander population in Sacramento County increased 44.7% from 1990 to 1998, with Asians and Pacific Islanders now 12.5% of that county's population. The Asian and Pacific Islander population in San Diego County increased 43.6% from 1990 to 1998, with Asians and Pacific Islanders now 10.7% of the county population and the Asian and Pacific Islander population in Orange County increased 42.9% from 1990 to 1998, with Asians and Pacific Islanders now 13.3% of that county's population. Meanwhile, San Francisco County's Asian and Pacific Islander population increased to 36.2% of the county population from 1990 to 1998. In 1998, Asians and Pacific Islanders were 21.9% of the population in Santa Clara County, 21.4% in San Mateo County, 19.3% in Alameda County, 15.8% in San Joaquin County and 13.3% in Los Angeles County.

Health Issues for California's Asians and Pacific Islanders

Asians and Pacific Islanders are often portrayed as the "model minority," with few health and other social problems. This stereotype masks the diversity and complexity of addressing the health issues facing California's Asians and Pacific Islanders. As evident from the past decade of Asian and Pacific Islander community health policy advocacy summarized above, many of the pivotal issues have remained unaddressed by policymakers. While there has been some incremental progress on raising awareness and responsiveness to some community issues, others - often fundamental ones such as data collection - persist as policy priorities. At the same time, structural policy changes in the health care delivery system, in government health programs and in the more general area of health and human services (e.g., federal immigration laws and policies, welfare reform, attacks on affirmative action and bilingual education, etc.) have had significant impacts on the health and well-being of Asians and Pacific Islanders in California.

Federal Government Efforts to Reduce Racial and Ethnic Disparities in Health

Given the significant percentage of the national Asian and Pacific Islander population residing in California it also is important to place these findings and recommendations into a national context. Last year, President Bill Clinton initiated several efforts to highlight and reduce the racial and ethnic disparities in health among Americans. First, President Clinton established a Race and Health Disparities Initiative as part of the One America dialogue and activities on race in America. In Fiscal Year 1999, the CDC created the Racial and Ethnic Health (REACH) program. Two projects focusing on Asian Americans were funded, one in Santa Clara, California focusing on cancer screening among Vietnamese American women and one in Lowell, Massachusetts focusing on cardiovascular health and diabetes among Cambodian Americans. In addition, The California Endowment recently funded an Asian American and Pacific Islander women's cancer screening program in Los Angeles and Orange County based on their REACH proposal.

DHHS also revised its draft of Healthy People 2010 to focus on the elimination of health disparities and to improve the quality of life as its two overall goals. Communities of color were particularly disturbed that the Healthy People 2000 Objectives had set different objectives by race/ethnicity, generally setting lower standards of health for minority populations. Asians and Pacific Islanders were largely irrelevant within the objectives, with only 8 initial and ultimately, 11 (after the midcourse review) objectives containing any reference to Asians and Pacific Islanders (on preventive screening/immunization, tuberculosis, hepatitis B among children, cigarette smoking among Southeast Asian males, two on growth retardation among children, source of primary care, nursing school enrollment, county health promotion programs, analysis/publication of data and addressing health disparities). These gaps were highlighted at the Healthy People 2000 Progress Review for Asians and Pacific Islanders conducted at the 1997 APIAHF "Voices from the Community" national conference.

Despite the progress in recognized racial/ethnic disparities in health and in setting a single, national standard for health for all Americans, the Healthy People 2010 process still is far from being responsive to and inclusive of the health needs of minority populations. In its comments on the draft objectives, APIAHF noted that no data on Asians and Pacific Islanders was available for 85 of the 141 objectives (60%).

The Healthy People 2010 Objectives were released in January 2000. The overall goals of the initiative are to a) increase the quality and years of healthy life and b) eliminate health disparities, through 467 objectives in 28 focus areas. Significantly, the objectives have race/ethnicity data elements that disaggregate "Asian" and "Native Hawaiian or Other Pacific Islander" populations, consistent with the 1997 Office of Management and Budget revised Standards for Maintaining, Collecting and Presenting Federal Data on Race and Ethnicity. The objectives also identify whether data was a) not collected, b) collected but not analyzed or c) collected and analyzed but not statistically reliable. This information will be useful in addressing future data needs. For example, out of 218 objectives with Asian and Pacific Islander data elements, 120 or 55% do not have data available for Asians or Pacific Islanders. Additional refinement of the objectives will be completed by November 2000.

Meanwhile, in June 1997, DHHS Deputy Secretary Thurm established an Asian American and Pacific Islander (AAPI) Initiative in response to a May 1997 request by national Asian and Pacific Islander health organizations to begin such a DHHS-wide initiative. During the summer of 1997, a DHHS Department Working Group (DWG) drafted a framework for its AAPI Initiative, including recommendations for improving a) Asian American and Pacific Islander access to and utilization of health and human services, b) Asian American and Pacific Islander data, c) research on Asian American and Pacific Islander health, d) training of Asian American and Pacific Islander health professionals and researchers, e) representation of Asian Americans and Pacific Islanders in the DHHS workforce and participation in DHHS operations and f) cross-cutting collaboration to enhance DHHS customer service to Asian Americans and Pacific Islanders. The DWG also sought and received comments on the draft framework from the Asian and Pacific Islander communities.

In the fall of 1997 through early 1998, each DHHS Operating and Staff Division developed an implementation plan in response to the framework and community comments. One Operating Division, the Health Resources and Services Administration (HRSA), sponsored a meeting with Asian American and Pacific Islander community leaders in March 1998 to review and comment on its implementation plan. In November 1998, DHHS released an Action Agenda for the AAPI Initiative, including implementation plans from each of the Operating and Staff Divisions. In July 1999, the Substance Abuse and Mental Health Services Administration (SAMHSA) conducted an Asian American and Pacific Islander Summit on Mental Health.

In June 1999, President Clinton signed Executive Order 13125, establishing a White House Initiative on Asian Americans and Pacific Islanders and a Presidential Advisory Commission on Asian Americans and Pacific Islanders. The purpose of the AAPI Initiative is to improve the quality of life of AAPIs by increasing the participation of underrepresented AAPIs in federal government programs (e.g. health, education, housing, labor, economic and community development, etc.). This executive order elevates the efforts of the DHHS to the White House and broadens it to include all executive departments and agencies. Staff for the White House Initiative have been hired and the members of the AAPI Commission were named in May 2000. The Commission's first townhall meeting was held in Los Angeles on July 24, 2000. The Commission's Interim Report is expected to be released in December 2000. Given the significant numbers of Asians and Pacific Islanders residing in California, the implementation of this White House Initiative will have vital importance for California.

Health Access

A basic issue for California's Asians and Pacific Islanders is access to health care. An estimated 24% of the Asians and Pacific Islanders in California were uninsured in 1996-1997. (University of California Los Angeles Center for Health Policy Research, 1999). However, the rates of health insurance coverage are dramatically different among California's Asian and Pacific Islander populations. For example, Korean Americans residing in California have the highest rate of uninsurance - 40% - among all racial/ethnic populations in the state. Only 35% of California's Korean Americans have job-based coverage; another 21% - the highest percentage among Asian and Pacific Islander populations - have privately purchased insurance. This may be due to higher numbers of Korean Americans who are self-employed or work for smaller employers who do not offer health insurance. Among Southeast Asians in California, the percentage of the population covered by Medicaid declined from 51% in 1994-1995 to 34% in 1996-1997. Because job-based coverage and privately purchased insurance for Southeast Asians remained fairly constant, this decline in Medicaid coverage resulted in a doubling of the uninsured rate among California's Southeast Asians from 11% to 23%. While 58% of Chinese Americans in California have job-based coverage, 30% remain uninsured. Among California's uninsured Asians and Pacific Islanders, 43% do not have a usual source of health care, 46% have not had a doctor visit in over a year and 13% either delay or go without needed treatment.

Medicaid Managed Care

A significant segment of the Asian and Pacific Islander population in California relies on publicly-funded health programs, such as Medicaid and Medicare. The conversion of the Medicaid program in California to managed care in twelve counties has had a particularly significant impact on California's Asian and Pacific Islander population. APIAHF reviewed many of these issues in its "Policy Report: Riding the Waves of Change: Improving the Health of Asian and Pacific Islander Women Under Medi-Cal Managed Care Expansion" in 1996. The report noted the number of Asian and Pacific Islander Medi-Cal beneficiaries that would be required to transition into Medi-Cal managed care, by ethnicity and primary language, in each of the twelve managed care counties. For example, according to 1995 Medi-Cal data, of the Asian and Pacific Islander primary languages spoken by Medi-Cal recipients, Vietnamese (n=25,563), Cambodian (n=18,396), Cantonese (n=5,386) and Mandarin (n=2,220) were the most common in Los Angeles County; Vietnamese (n=26,054) and Cambodian (n=2,612) in Santa Clara County; Hmong (n=8,421), Lao (n=2,045) and Samoan (n=1,708) in Fresno County; Vietnamese (n=7,715), Cantonese (n=4,257) and Cambodian (n=2,390) in Alameda County; Cantonese (n=7,367) and Vietnamese (n=4,103) in San Francisco County; Lao (n=3,446) in Tulare County; and Vietnamese in San Bernardino County (n=3,132). Ensuring language access and cultural competence by Medicaid managed care providers will be a vital issue for these Asians and Pacific Islanders in California.

Among the report's recommendations for managed care organizations:

The APIAHF report also made recommendations to the California Department of Health Services:

Children's Health Insurance Program (Healthy Families)

One of the most significant changes in health access in California has been the implementation of the Children's Health Insurance Program, called Healthy Families, beginning in June 1998. Estimates are that 328,000 California children are eligible to enroll in Healthy Families. As of March 13, 1999, only 82,883 children, or 25% of those eligible, had enrolled in the program. There has been significant criticism of the outreach and enrollment efforts for Healthy Families, particularly among communities of color. For example, estimates were that up to three-quarters of the children eligible for Healthy Families throughout the state are Latino. However, as of March 1999, only 47% of the children enrolled were Latino.

Of the children enrolled in Healthy Families through March 1999, over 18% are Asian and Pacific Islander (15,064). The relatively high enrollments of Asian children can be misinterpreted because a significant percentage of the enrollments are directly attributable to the outreach efforts of two Asian community-based organizations, North East Medical Services (NEMS) in San Francisco and Korean Health Education and Information Referral (KHEIR) in Los Angeles. As of March 1999, NEMS had enrolled 1,182 of the 3,358 Chinese children enrolled in San Francisco County and KHEIR had enrolled 1,041 of the 1,625 Korean children enrolled in Los Angeles County. Together, the efforts of these two organizations accounted for approximately a quarter - 23% - of the total number of Asian children enrolled statewide.

The outreach efforts of NEMS and KHEIR have been well-documented. For example, of 154 Chinese parents surveyed in San Francisco in July 1998 by the Medi-Cal Community Assistance Project, 77% were familiar with the Healthy Families program. Of those familiar with the program, 16% cited NEMS and 47% cited Chinese television and radio spots (paid for by NEMS) and news coverage (often featuring NEMS' efforts) as their source of awareness about the program. Only 3% cited the English language outreach conducted by the DHS media contractor. Some will point to the high enrollments of Asian children as one of the successes of the MRMIB and DHS in the Healthy Families program. However, these successes only reinforce the need for community-based outreach strategies to effectively reach California's Asian and Pacific Islander populations.

Implementation of Federal Welfare and Immigration Reform

California's Asians and Pacific Islanders also will experience the continuing adverse impact of the 1996 federal welfare and immigration reform laws. For now, advocacy efforts have resulted in state-funded safety net programs for the elderly, disabled and indigent who have been disqualified from receiving federal public benefits. However, the maintenance and funding for these state programs will be critical to monitor. APIAHF's "Policy Report: Beyond the Safety Net: Health Services for Low-Income Asian and Pacific Islander Women and Children in California" examined this impact in detail.

Among the report's recommendations for California policymakers:

Asian and Pacific Islander Health Professionals

Despite the "model minority" stereotype, some Asian and Pacific Islander populations continue to be severely underrepresented among health professions. For example, a 1995 APIAHF study found that although there is an "oversupply" of Asian and Pacific Islander physicians as a whole, there is a severe shortage of Southeast Asian and Pacific Islander physicians in California.

Asian Physicians per capita base on Coutry of Origin

Race/Ethnicity

Number of Physicians
in California
in 1990

Total Population
in California
in 1990

Ratio of
Physicians to Population
(per 100,000)

Chinese

3,940

704,850

559

Filipino

1,933

731,685

264

Japanese

1,404

312,989

449

Asian Indian

1,882

159,973

1,176

Korean

1,351

259,941

520

Vietnamese

487

280,223

174

Hawaiian

15

34,447

42

Laotian

0

58,058

0

Cambodian

0

68,190

0

Thai

50

32,064

156

Samoan

0

31,917

0

Guamanian

0

25,059

0

Other AAPI

402

146,263

275

Total AAPI

11,464

2,845,659

403

 

Physicians per capita base on Ethnicity

Race/Ethnicity

Number of Physicians
in California
in 1990

Total Population
in California
in 1990

Ratio of
Physicians to Population
(per 100,000)

Non-Hispanic White

56,736

17,029,126

333

Black

2,655

2,208,801

120

American Indian,
Eskimo, Aleut

149

242,164

62

Non-Hispanic
Other Race

62

56,093

111

Hispanic

3,933

7,378,178

53

Total

74,999

29,760,021

252

Source: 1990 Census, 5% PUMS dataset and EEO file.
Copyright APIAHF, 1995

Recommendations to Improve the Health of California's Asians and Pacific Islanders

It is evident from this review of the past decade of health policy advocacy by California's Asian and Pacific Islander communities that "new" policy recommendations or agendas are unnecessary. There has been an abundance of findings, reports and recommendations. These recommendations can be summarized as follows:

Improve Data Collection, Analysis and Dissemination Regarding California's Asians and Pacific Islanders

A persistent recommendation from all the Asian and Pacific Islander community advocacy efforts of the past decade is to collect, analyze and disseminate all health data at least by race/ethnicity, and then by each Asian and Pacific Islander ethnic/national origin subpopulation. Compliance with the revised Office of Management and Budget Statistical Directive (1997) would achieve this important policy recommendation. Data regarding primary language also will be vital to collect, monitor, analyze and disseminate. Such data will be especially important in ensuring linguistic access and cultural competence in all health education, disease prevention and primary care programs. With the enactment of disqualifications from many federal health and human service, data regarding citizenship and immigration status also will be increasingly relevant. However, it will be important to protect the confidentiality of such data and not to confuse applicants and recipients about eligibility.

Improve Access to Health Care for All of California's Asians and Pacific Islanders

Given the high rate of uninsurance among California's Asian and Pacific Islander residents, both broad and incremental reforms in health care will be vital to California's Asian and Pacific Islander communities. Until policymakers consider access to health care as a right, any reduction in the number of Asians and Pacific Islanders in California without health coverage is likely to be minimal. For example, many Asians and Pacific Islanders who own or work in small businesses will never be able to afford health care in an employment-based health care system. Similarly, without broader access to health coverage for extended family members (parents, grandparents, etc.), many Asian and Pacific Islander households will continue to face challenges in providing coverage for all household members.

For many of California's Asians and Pacific Islanders, even if eligible for private or public health coverage, systematic barriers will continue to hinder full access to health care. Whether the program is private managed care, MediCal managed care, geographic managed care or Healthy Families, the ability to successful enroll, maintain coverage and utilize available care will continue to be a challenge for the linguistically isolated, and for immigrants and refugees.

Ensure Quality of Health Care for California's Asians and Pacific Islanders

Even for those Asians and Pacific Islanders who are able to access health care in California, there is no assurance that the health care received will be quality health care. Much of the public policy debate about health care today focuses on the role of consumers (patients or "members" of health plans) in having choices and making informed decisions about their own health care. However, for many Asians and Pacific Islanders, there are structural linguistic and cultural barriers in obtaining sufficient information and knowledge about the choice of provider, the choice of a primary care provider, utilization of health education and prevention programs, the quality of care and health outcomes.

In addition, another persistent recommendation from the past decade of Asian and Pacific Islander community advocacy is the need to tailor health promotion/disease prevention and clinical treatment programs for specific Asians and Pacific Islander populations. For example, it is vital to identify, diagnose and treat those conditions that are more prevalent among Asians and Pacific Islanders, whether it is tuberculosis, Hepatitis B or breast and cervical cancer. There are also challenges to address the most common behaviors and practices that increase health risks among Asians and Pacific Islanders, whether it is stress, smoking, poor nutrition, or failure to utilize preventive screening. Programs must be community-based and delivered by community providers who are known, trusted and credible in the community.

At the core of these challenges is the integration and implementation of the principle of cultural competence into any standard of quality health care. Just as a health provider would not be viewed as qualified if lacking in a working knowledge of the relevant diagnoses of a particular patient population (e.g. a gerontologist treating pediatric patients), it is vital that "quality" becomes equated with the knowledge, skills and experience to effectively provide health care to Asians and Pacific Islanders in California.

Promote Health Professions Development Among California's Asians and Pacific Islanders

Health professions development programs must be focused on recruiting, training and sustaining health professionals from underrepresented Asian and Pacific Islander communities in California. There are additional challenges in developing and training allied health professionals, including health interpreters, mental health workers, and researchers in community and population health that will be available to serve California's diverse Asian and Pacific Islander populations. The elimination of affirmative action programs for women and minorities by the University of California in 1997 and the passage of Proposition 209 have further eroded the opportunities for underrepresented Asians and Pacific Islanders to enter the health professions. The myth of the model minority, especially in educational achievement, also will hinder the development of health professionals from underrepresented Asian and Pacific Islander communities. Both governmental and community-based efforts to develop linguistically and culturally competent health professionals will be vital to ensuring access and quality of health care programs and services for California's Asians and Pacific Islanders.

Conclusion

As we begin the new millennium, California has the opportunity to provide significant leadership in improving the health of its Asian and Pacific Islander residents. Such leadership can be a national model as the Asian and Pacific Islander population in the entire United States continues to grow.

The past decade has witnessed important advocacy efforts by the Asian and Pacific Islander communities in California to highlight our health needs and to promote proactive, community-based solutions to enhance our collective health. At the same time, there remains frustration that fundamental barriers continue to be faced in ensuring both access to and quality of care. As evident from this report, many of these issues and recommendations are not new: they have been the same, persistent themes articulated by California's Asian and Pacific Islander communities throughout the past decade. The Department of Health Services Task Force on Multicultural Health has a pivotal role in focusing the attention of California's policymakers and administrators on these issues and recommendations. It is hoped that this report can be a catalyst for emphasizing the importance of these issues and for decisive action that begins to implement these critical recommendations.

References

Asian and Pacific Islander American Health Forum. Comments on Draft Healthy People 2010 Objectives. Submitted to Department of Health and Human Services, December 15, 1998.

Asian and Pacific Islander American Health Forum. "Policy Report: Beyond the Safety Net: Health Services for Low-Income Asian and Pacific Islander Women and Children in California." August 1999.

Asian and Pacific Islander American Health Forum. "Policy Report: Riding the Waves of Change: Improving the Health of Asian and Pacific Islander Women Under Medi-Cal Managed Care Expansion." December 1996.

Asian and Pacific Islander Task Force. Report on the Year 2000 Health Promotion Objectives and Recommendations for California. May 1992.

Asians and Pacific Islanders for Reproductive Health. The Health and Well-Being of Asian and Pacific Islander Women. November 1995.

California Commission for Economic Development. California Asian Health Issues in the 1990's. April 1990.

California Department of Health Services. Analysis of Health Indicators for California's Minority Populations. February 1994.

California Department of Health Services. Healthy Families Program and Medi-Cal for Children: Annual Outreach Plan for Fiscal Year 1999-2000 and Evaluation of Fiscal Year 1998-1999. April 1999.

California Pan-Ethnic Health Network. Diversity in Action Summit and Policy Report. 1999.

Levan R, Kagawa-Singer M and Wyn R. "Policy Brief: Declining MediCal Coverage Leades to Increasing Uninsured Rate Among California's Asian Americans and Pacific Islanders." University of California Los Angeles Center for Health Policy Research. April 1999.

MediCal Community Assistance Project."Outreach for Healthy Families: Impact of a Community-Based Outreach Program in San Francisco's Chinatown" (MedCAP Fact Sheet). Undated.

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