Unveiling Barriers to Healthcare after Insured By Affordable Care Act : Experiences of Self-Employed Korean Immigrants

Background and Purpose: The individual mandate policy of the Affordable Care Act (ACA), originally implemented as of January 1st, 2014, compels historically disenfranchised non-elderly adults to obtain health insurance. Studies have highlighted a notable decline in uninsured rates among non-elderly adults, particularly among racial/ethnic minorities and immigrants. Many immigrants, including those who migrated from South Korea, enrolled in qualified health plans (QHP) under the ACA, motivated by federal subsidies for paying the premium as well as penalties for not having health insurance. However, disparities in healthcare access persisted, especially among immigrants and racial/ethnic minorities. Non-financial barriers associated with language and cultural norms impede access to care despite expanded coverage by the ACA. This study aims to explore barriers to healthcare that emerged after the implementation of the individual mandate policy of the ACA among self-employed Korean immigrants who were previously uninsured prior to this federal policy after their migration.

Methods: The study conducted in-depth interviews with 20 self-employed Korean immigrants in the Greater Los Angeles area. Participants, who were Korean speaking with significant self-employment history, were purposively sampled from diverse social settings and through referrals. Most participants did not have health insurance before ACA’s individual mandate came into effect in 2014, and 16 of them obtained QHP. Participants were asked about their experiences with and perspectives on the health insurance which they obtained due to the ACA. We conducted thematic analysis to identify shared experiences and viewpoints as to newly emerged barriers after they became insured by QHP.

Results: Respondents highlighted both financial and non-financial challenges in accessing healthcare. Three key themes emerged regarding the barriers to care. Firstly, the theme of "Affordability: still burdened by out-of-pocket expenses" was prevalent, with reports indicating that many respondents found insurance premiums and out-of-pocket costs to remain high despite the federal subsidy. Secondly, the theme of "Comprehensibility: challenge in understanding insurance policies" emerged from anecdotes where respondents expressed confusion about coverage details, compounded by a lack of friends or acquaintances knowledgeable about insurance policies. Even ACA navigators fluent in Korean struggled to provide clear answers about the benefits of the QHPs they were enrolled in. Lastly, the theme of "Accessibility: non-financial barriers stemming from linguistic and cultural identity" underscored the limited cultural and linguistic competencies of in-network providers, resulting in the prolonged wait times to see Korean-speaking providers due to their scarcity.

Conclusions and Implications: Expanding insurance coverage alone may not be sufficient to reduce disparities in healthcare access for Korean immigrants who are predominantly small business owners. It is imperative to provide comprehensive yet culturally tailored education on health insurance for immigrant populations. This requires policy efforts to increase the number and capabilities of navigators available to immigrants with language barriers. Finally, further research is needed to understand where and how immigrants access information about health insurance, facilitating the development of effective health education programs leveraging these channels.