Comparison of Barriers to Health Care before and after Receiving Health Insurance Due to Aca's Individual Mandate Among Self-Employed Korean Immigrants

Background/Purpose: Despite higher income and more formal education, Korean immigrants had lower health insurance coverage compared to any other ethnic group in the United States. Poor access to care among Korean immigrants was attributed to this high uninsured rate and many expected to see improved access to care if they were insured. Yet we posited that other remaining factors might undermine access to care for groups disfranchised from health care or unexpected barriers might occur even after individuals gain health insurance. Thus, we conducted a qualitative study with Korean immigrants who rarely had health insurance prior to the Affordable Care Act (ACA) to explore whether barriers affect access to care before and after receiving health insurance and what changes in health care use occurred in this group following the health insurance mandate.

Methods: Purposive sampling from churches primarily serving ethnic Koreans was conducted to recruit 24 self-employed Korean immigrants (12 men, 12 women; mean age = 51; weekly working hours = 50.33; monthly income = $5,650) living in ethnic enclaves in Southern California. Recruited participants rarely had health insurance before ACA’s individual mandate was implemented, yet currently had health insurance. In-depth individual interviews explored different aspects of barriers to health care before and after receiving health insurance. We also assessed coping strategies to secure access to care when uninsured. Interviews were transcribed verbatim, coded, and analyzed using coding consensus, co-occurrence, and comparison methods.

Results: With a few exceptions, most interviewees did not have health insurance before the ACA and purchased health insurance to avoid penalties. Before ACA implementation, a major barrier to access to care was not having health insurance due to cost and the inconvenience of using health insurance, such as long wait time. Most participants coped with these barriers by paying with cash, relying on over-the-counter medicine, or traveling to Korea for health care. After participants received health insurance, new barriers emerged that were largely related to linguistic issues. First, interviewees didn’t use health insurance because they couldn’t comprehend their insurance policy and continue to pay cash instead of using their insurance. Second, a lack of skilled coethnic liaisons meant Korean immigrants did not receive accurate information related to health insurance, suggesting few reliable sources of health information. Third, interviewees described frustration with the lack of Korean-speaking physicians in their network, which also affected the quality of health care.

Conclusions: Having health insurance did not seem to improve access to care in this historically disenfranchised group. New barriers emerged and many chose not to use health insurance, instead paying with cash to cope with those new barriers. Participants regarded health insurance as a way to avoid penalties. It is imperative to develop programs or services that explicate health information for marginalized groups whose English proficiency is low and whose social networks feature coethnic people who don’t provide reliable health information. Further studies should explore factors correlated with health literacy and quality of health care experiences among Korean immigrants and other groups disenfranchised from the health care system.