ASIA Program Evaluation: Health Insurance Awareness

Study

December 16, 2016

Phyllis Braudy Harris, Ph.D., Professor and Chairperson

Department of Sociology & Criminology,
John Carroll University

Student Research Team:

Madison Chickos Kathleen English

Tara Kelley Vanessa Kreiss
Brianne ORourke Maria Pangori
Mae Saunders Tori Williams
Kaleigh Wagner Veronica Zielinski
 ASIA Program Evaluation: Health Insurance Awareness
Study
Background
In fall 2016, an advanced sociology class on poverty, welfare and social justice at John Carroll
University (JCU) conducted an evaluation of the Health Insurance Awareness Program of ASIA,
INC. ASIA is a non-profit organization serving the Asian American and Pacific Islander
Population in the Cleveland and Akron areas. Most of their clients are recent refugees or
immigrants. The main contacts at ASIA were: Kitty Leung, MSSA, LSW, the Manager of the
Children, Youth and Family Services Department, and Cathy Vue, MPH, the Assistant Manager
of Community Health, Evaluation, and Research Institute Department.

The main goal of the program is to help ASIAs community members gain a better understanding
of health insurance. For this study questions were also added to ascertain the participants
perspective on health and their health care providers. A qualitative evaluation study was designed
by Cathy Vue in consultation with the professor, Dr. Phyllis Braudy Harris. Before the study
began, the research proposal was approved by the JCU Institutional Review Board (IRB) for the
Protection of Human Subjects.

Methodology
Data were collected through 3 focus groups: one with the Korean community, one with the
Chinese community, and one with the Nepali/ Bhutanese community, resulting in a sample size
of 35 people. Purposive sampling techniques were used and staff from ASIA contacted the
participants by phone to invite them to join the focus groups. However, a number of the
participants in all 3 groups were unclear about the purpose of the focus groups, which initially
caused some confusion. Once the informed consent forms were read and explained the confusion
was lessened. Informed consent forms were translated into the participants native language and
signed by the participants. The JCU students were divided into teams of three, each with a team
leader. Each team consisted of 3-4 students who had the responsibility for conducting one of the
focus groups. Two of the focus groups took place at the Akron office of Asia. The Korean focus
group took place at a Korean Church in Ashtabula. The focus groups lasted 60 to 90 minutes and
interpreters were used as most of the participants were non-English speaking, except for the
Korean focus group because all the participants spoke English. The focus groups were audio-
taped with permission and later transcribed by the research team.

The demographic characteristics of the Korean sample (N=8) consisted of: a) 3 females and 5
males, b) all were 65 or older, c) all participants spoke English, and d) two of the focus group
members were physicians. These participants had been in the United States for a while and were
fairly well assimilated. The Chinese focus group (N=21) consisted of: a) 19 people of Chinese
ethnic background, 1 Caucasian, and 1 person who was Japanese, and b) 18 females and 3 males.
The Nepali/ Bhutanese focus group consisted of: a) 3 females and 3 males, and b) all participants
were refugees whose number of years in the U.S. ranged from two months to 7 years, two people
being only in the United States for two months. Thus, the overall sample of participants in the
study mirrored the diversity of the type of clients ASIA services.

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Research Findings
The qualitative findings are analyzed by the common themes that emerged from the focus groups
and in response to the questions asked (see appendix), and broken down by each group: Korean,
Chinese, and Nepali/ Bhutanese Then the common themes across all three groups are discussed.

Korean Focus Group Responses (N=8). There were five major themes: 1) Reliance on
Medicare, 2) Confusion about health insurance cost and coverage, 3) The role of the Church in
the communitys life, 4) Role of the family doctor, and 5) The importance of preventive health
care. The narrative data below support these findings. The group discussion was dominated by
the two physicians, which limited the discussion.

1) Reliance on Medicare:
I was very sick. I went to Emergency Room and they checked everything and
when I over there I no charge [because of Medicare], it was surprise to me, very
surprise to me.
Medicare is primary and Medical Mutual is secondary. I dont have to pay any
money to go to doctor.
We asked: Does this make a difference on how often you see your doctor? They
responded, Yes, big difference; and all nodded their heads in agreement.

2) Confusion about health insurance cost and coverage:

I make $1,500 a month from social security $1,500 not enough living here...I
need help to go to hospital... Actually, I paid 20% whenever I have problem and I
want covered. But I sign up and send it to them, one month later they said, they
tell me, You not very good for help, your income is a little bit higher... how much
line is low income? Do you know about that?
How does that work for retired person?
What kind of person available for Medicaid?
What income is available Obamacare?
Government...low income and high income person How low the low income
person to help insurance? How much low income is to get help?
After I retire, I dont know what will happen.

3) Role of the Church in the communitys life. The church the participants of this focus group
attended was an integral part of their health, social, and economic well-being. There were
two major subthemes that emerged on this topic: a) health/social care and b) a lending
circle.

a) Health/Social Care
Church members care for each other.
Its a special kind of community.
I have a good doctor [referred by church members]. Im happy for that
I have a doctor and Medicare; he is my doctor! [points to other participant].

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 Yes, I am comfortable They are also a friend.
Our church family doctor references specialists if we need it.
I am comfortable asking questions [ to my doctor] because I trust my friends [who
referred the doctor].

b) Lending Circle
An unexpected topic that came up during the focus group was the mention of a
Korean-Christian health lending circle among church members
o One participant recalled having major surgery and being able to pay the
bills completely using the funds from the lending circle.

4) Role of the family doctor. There was a strong emphasis on the importance of having a
family doctor the participants could trust. In this case, most of the group had the same
family doctor that was recommended by other church members.
Once they have good relationship with family doctor and he make reference to
the special doctor each time some health problems...thats the best way and almost
everybody here has secondary specialty doctors from their family doctor.
The family doctor refers you to a specialist.

5) Understood importance of preventive health care

In my case, I go to doctor every six months, I have problems, my sugar, blood
sugar high so I go to check me out. Usually go to doctor twice a year, every six
months.
They give us notice for blood or urine testing two times a year...See doctor for
checkup for free. If they send me letters for checkups, I will go...They will pay for
it...Its a good indicator of being healthy. That letter is a very good indicator of
their service.
Silver Sneakers covers YMCA membership and I am able to go workout.
She exercises every day!
I am age 75, but I play golf very nicely.
We all play golf. We are over 75.

So in summary, among the participants of this Korean focus group, though they rely on
Medicare, there was confusion over costs and what medical services were covered among all the
group members. And this was a fairly well educated group of individuals, some who were in the
medical profession. On the whole the group understood the importance of preventive health care
and practiced it. Their church community played an important part in their lives, including
referrals to physicians and providing financial support for expensive health care procedures.

Chinese Focus Group Responses (N=21). There were 4 major themes: 1) Confusion about
Medicare vs Medicaid, 2) Lack of Transportation, 3) Importance of Exercise, and 4) Relationship
with their Physician. The narrative data below supports these findings.

1) Medicare vs Medicaid:
The difference between Medicare and Medicaid is hard to understand.

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 What about my shingles shot, I am so worried about it! I dont know who is
going to pay for it!
Its not fair, we need to know everything, whats going on with my insurance.
Which one is the primary if I go to the hospital if I have both [Medicare and
Medicaid]?
Why are there even two? Do we need them both?
Who decides what I have to pay when I have a doctors visit?
Can I see the doctor whenever I need to?
I am not sure if I have Medicaid or Medicare, or what is covered by these two
things. Is there a place that I can get the information about what health insurance
I have?
They (ASIA) still doesnt understand, we need information again. I dont get the
difference. Having papers would help.
I just dont know the difference. What should I get?
Can I have both Medicare and Supplemental Insurance.
Sometimes I feel that the government is making it too hard for people to get the
help that they need. We deserve these simple things. Without our health, we
cannot live. The government needs to see that we matter too. Why must they make
it so hard.

2) Lack of transportation:
I am concerned for when I get to the point where I can no longer drive my car
and I will need to go to the doctor but cannot get to the place. What if I do not
have someone to drive me so I will not be able to take care of myself at my older
age?
How do I find out what hospital is close to me and also takes my health care if I
cannot go to the ASIA Clinic?
I have a car, but for some people getting transportation is a necessity.
What is the best bus line to take?
I thought that ASIA had transportation to the health clinic, I assumed that is
how people got there.
Where would I park? Do I pay? Would it cost me more?
ASIA should help us get to the doctors so I feel safe.
If I had a way to get transportation to the doctors, then I wouldnt be scared. I
do not like walking in dark.

3) Importance of exercise: All the participants said they exercised on a regular

basis.
I do the dumbbells and small weights in the exercises room.
There is a Zumba class offered that not many people know about that I do
often.
We do a lot of walking every day to help stay in good health.
I like to go swimming when I get the chance.

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 I walk or ride a bike to most of the places I go to so that helps me stay in shape
and I also try to not eat bad.

4) Relationship with their physician. Because of the language barrier even with a
translator, information for some questions was gathered by asking the participants
to raise their hands in response to some questions about their health care provider.
11 out of 21 people see the doctor yearly.
1 out of 21 people called their doctor in the past year to get a question answered.
5 out of 21 people feel comfortable with their doctor.
9 out of 21 people took care of their health by seeing a doctor

Thus, among the participants in the focus group there is much confusion over health insurance
coverage and concern about transportation to access health care. Over half the group have yearly
physicals, though their relationship with their health care provider is tenuous. However, the
participants understand the importance of physical exercise as a key to preventive health care.

The Nepali/ Bhutanese Focus Group Responses (N=6). There were four major themes: 1)
Health, diet, and cleanliness, 2) Importance of and confusion about health insurance,
3) Importance of the family doctor, and 4) Stress and barriers that affect health.

1) Health, diet, and cleanliness:

It is about staying healthy, staying with good hygiene, taking showers, eating
good food, no eating bad food.
[Good health] is staying healthy and cleaning the house and making sure it is
safe and stuff like that is being healthy.
Back in Nepal, everyone knows what they are eating and you can see. Here, you
dont know what kind of food you are eating and what is in the food.
It is not clear, but what diet do we need to eat to get healthy. What type of food
will get me healthy?
Probably being healthy means not drinking like alcohol or smoking. Things like
worrying about kids are having me be unhealthy by drinking and smoking.
It is like, as an adult, many people dont want to not drink. When things are bad
they want to drink to take the pressure off. Sometimes I know not to smoke but I
have to smoke cigarettes. All the tendencies I have from family like my child gets
seizures, I need to smoke to get over myself. Coming over here [to the United
States] and having so much pressure and histories and being a parent and not
knowing enough information [about the United States] is the main reason I have
health issues.

2) Importance of and confusion about health insurance:

Without Insurance we cant do anything.
Insurance can be the one that saves your life if you need it.
I dont know much, but when I get sick I go to hospital and doctor prescribes
something.

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 I use it in emergency, but I dont know that much about it.
What is the difference between Medicaid and insurance?
I want to learn. I still need to learn. I dont know enough. I want to learn more.
I dont have any questions. I cant come up with one. I dont even know what
health insurance do. When I get sick I go to the hospital. Thats all I know.

3) Importance of the family doctor:

I see my family doctor a lot. So, yes Im comfortable [with him].
If I have questions, I will ask.
They give me a family doctor. Since I have relatives close who see this doctor,
this is who I see.
I go to the family doctor first. Then he gives me names of other doctors. If I need
it, eye, bones-you know.
When the nurse or doctor is female, being male I feel uncomfortable. But I said
it! Cause I dont want to be sick, but I do feel uncomfortable at times.

4) Stress and barriers that affect health:

Coming over here and having so many pressures and not being able to do
anything and not having any knowledge. It is hard.
As adult a lot I dont want to drink often, but when I am in tensions, I drink
alcohol because there is so much pressure.
I know I should not smoke, but sometimes I do because it makes me feel good.
Theres just too many issues. It helps me.
When I miss the transportation they provide it takes one month to reschedule
and them I cant get to the hospital. How do I get there?
I do get worried. I have nightmares I wont be able to get citizenship.
I see a lot with my people. They think about suicide. It does get them worried
with bad nightmares.
When I first came here I had a caseworker, the one who picked the doctor. The
caseworker is from the same community. He showed me where to go, which bus to
take.
When I have questions I go to ASIA and I ask them. I have a class; they teach
me; they have class now.

Thus, for the Nepali/ Bhutanese participants in this focus group, there is much confusion about
health care insurance but they do understand the importance of having it. There is concern about
eating a healthy diet in the US and what that entails. Their meaning about health is tied up with
issues of cleanliness and safety, and the relationship with the family doctor is important. The
stress involved with the relocation and concern about citizenship is expressed, and though they
know alcohol and smoking are negative ways of coping, it provides comfort for some people.
Services by ASIA are recognized as being helpful.

Conclusion and Recommendations

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There are many limitations to this study. The sample size is small and was chosen by the staff of
ASIA. Information for two focus groups was filtered through translators, which impacted the
depth and length of the responses. Initially participants did not understand the purpose of the
focus groups, so that took a while to explain. Participants also at first thought that they were
coming to the groups to get information about health insurance. However, even given these
limitations, there were some consistent patterns across the 3 focus groups, as relates to the
purpose of the study: assessing participants knowledge about health insurance and health care
access, their perspective on health, and their relationship with their health care provider.
First of all, among the three groups of participants, there was much confusion about health care
insurance. Since the majority of the sample was older, much of that confusion related to coverage
and costs related to Medicare and the differences with that and Medicaid. Not much discussion
was around the Affordable Care Act. There was also concern about the need for transportation to
health care appointments, which impacts access. Participants understood the importance of
taking preventive health care measures, such as keeping regular health care appointments, and
regular physical exercise. It was also apparent from the data, that the role of the family doctor
was paramount, with many members of the specific communities going to the same doctor,
within that community, and that physician was the gatekeeper to other health care providers.
Given these findings, below are some recommendations:

Recommendations:
1) There is a need to provide more information about Medicare and Medicaid. Multiple
methods of communications to fill this knowledgeable gap would be helpful, such as: a)
clear and simply written pamphlets in their native languages available at multiple
locations: ASIA, family doctors offices, local Asian food markets, and community
churches, and b) more educational information sessions held at ASIA and other local
community gathering places, which is well publicized, with transportation provided. The
use of social media as another venue would depend upon the computer access and
literacy of the participants.

2) Transportation for health care is a concern. Some possible solutions are: pamphlets that
highlight the different bus routes to the clinic and local hospital, recruiting more
volunteer drivers from the specific communities, helping to facilitate carpools, assistance
in getting drivers licenses, if and when that is possible.

3) Learn more about the Korean communitys lending circle to assist with the cost of health
care expenses. Evaluate if this is a possible model that is transferable to other
communities.

4) The family doctor is the gatekeeper to the access of other health care providers. Pursue
more partnerships with these physicians.

5) Encourage and continue the emphasis on preventive health care, especially regular
physical exercise. Make participants aware of such opportunities already available in the
community and/or at ASIA.

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 APPENDIX
Focus Group Questions
Health
1. What does health mean to you?
2. How do you take care of your own health?

Health Insurance
3. How important is health insurance to you and your family?
4. How do you currently use your health insurance?
5. What is the best way to learn about how to use health insurance?
6. What are things you want to learn about health insurance?

Health Providers
7. How do you select your health care provider(s)?
8. From what types of health providers do you get health advice?
9. How do you feel about asking your doctor questions about your health?
10. When was the last time you saw your health provider/doctor?