Socio-Cultural Factors Associated with a Decision Not to Purchase Health Insurance Among Self-Employed Korean Immigrants in an Ethnic Enclave, California

Background and Purpose: Health insurance is one of the most influential enabling factors for healthcare service utilization in time of need. Before the mandate of the Affordable Care Act in 2014, Korean immigrants were consistently reported the least likely to purchase health insurance among Asian ethnic groups. This finding was startling because relatively high socioeconomic status of Korean immigrants hinted higher likelihood of having health insurance. Previous studies debunked a belief that high prevalence of self-employed is a culprit for the lower proportion of the insured among Korean immigrants. Based on the Socio-Cultural Framework of Service Disparities (SCFSD) emphasizing significance of ethnic community in health care use, we aimed to explore influence of socio-cultural factors related to health insurance purchase among Korean immigrants living in an ethnic enclave, Los Angeles Metropolitan area. We particularly focused on 1) what non-economic factors are associated with previous decision not to buy health insurance and 2) whether ethnic community was influential for decision not to buy health insurance.

 

Methods: We recruited twenty four Korean immigrant adults (18 years old and above) who identified themselves as self-employed and being uninsured for substantial period before 2014 via snowball sampling in which a respondent helped find subsequent potential interviewees. Each interview lasted for between 30 minutes and 90 minutes and four interviews were conducted by telephone and another eighteen interviews were administered in in-person meeting. Average age was 50.71 years old and average weekly working hours was 50.33. Average monthly income was $5650.00. All interviews were conducted in Korean since every participant felt comfortable by talking in the language. We asked why they didn’t purchase health insurance after migrating to US. Korean transcripts were produced and two bilingual interpreters translated into English. Authors analyzed transcripts by the constant comparative analysis method  to explore whether any socio-cultural factors within Korean community were influential.

 

Findings: Although participants consistently emphasized the importance of economic factors, such as no financial resources to purchase health insurance, participants showed that their perception on economic difficulty was associated with socio-cultural factors. For instance,  respondents refused to buy health insurance after migration because it was perceived too expensive when compared to the monthly payment that respondents had paid in South Korea. Or, their negative perception upon the effectiveness of health insurance was shaped during early contact with US health care, without being challenged by new information about health insurance. Lastly, majority had sought information exclusively from Korean immigrants.

Conclusion and Implications: The SDSFD was helpful to unravel significance of socio-cultural factors associated with Korean immigrant’s health insurance purchase decision. Future studies are recommended whether applying the SDSFD facilitate understand process by which other immigrant groups decide to purchase health insurance. Lastly, programs aiming to reduce uninsured people among a particular cultural group requires to consider community-level peculiarities, such as cultural norms, to better address barriers to care.