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Socio-cultural determinants of healthcare access among Korean Americans

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Socio-cultural determinants of healthcare access among Korean Americans

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SOCIO-CULTURAL DETERMINANTS OF HEATLHCARE ACCESS
AMONG KOREAN AMERICANS

by

Chung Hyeon Jeong

A Dissertation Presented to the
FACULTY OF THE USC GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF PHILOSOPHY
(Social Work)

August 2020

Copyright 2020 Chung Hyeon Jeong
ii
TABLE OF CONTENTS

List of Tables ................................................................................................................................. iii

List of Figures ................................................................................................................................ iv

Abstract ........................................................................................................................................... v

Chapter 1: Introduction ................................................................................................................... 1
Background and Significance ............................................................................................ 1
Specific Aims ....................................................................................................................... 6

Chapter 2: Manuscript 1.................................................................................................................. 7
Abstract ................................................................................................................................. 7
Introduction .......................................................................................................................... 9
Methods............................................................................................................................... 13
Results ................................................................................................................................. 15
Discussion ........................................................................................................................... 23

Chapter 3: Manuscript 2................................................................................................................ 27
Abstract ............................................................................................................................... 27
Introduction ........................................................................................................................ 29
Methods............................................................................................................................... 32
Results ................................................................................................................................. 35
Discussion ........................................................................................................................... 41

Chapter 4: Manuscript 3................................................................................................................ 46
Abstract ............................................................................................................................... 46
Introduction ........................................................................................................................ 48
Methods............................................................................................................................... 52
Results ................................................................................................................................. 57
Discussion ........................................................................................................................... 66

Chapter 5: Discussion ................................................................................................................... 72

References ..................................................................................................................................... 77

Appendices .................................................................................................................................... 91
Appendix A. Semi-structured Interview Guide (Study 1) ....................................... 92
Appendix B. Survey Questionnaire (English) ......................................................... 96
Appendix C. Survey Questionnaire (Korean) ....................................................... 104
Appendix D. Random-intercept Models of Respondents’ Satisfaction with
Health Information by Alters’ Characteristics ................................. 113

iii
LIST OF TABLES
Table 2.1. Demographic Characteristics of Sample and Overall Perceptions
with Healthcare Systems in the U.S. and Korea .......................................................... 16
Table 3.1. Sample Characteristics ................................................................................................. 36
Table 3.2. Comparison of Perceptions of Health Insurance by Status of Enrollment .................. 38
Table 3.3. Levels of Positive Perceptions of Health Insurance by Enrollment History ............... 39
Table 3.4. Effects of Perceptions of U.S. Health Insurance on Health Insurance Coverage
Among Korean Americans ........................................................................................... 40
Table 4.1. Sample Characteristics ................................................................................................. 59
Table 4.2. Characteristics of Health Discussion Networks by Alters’ Attributes ........................ 60
Table 4.3. Descriptive Statistics on Sizes of Health Discussion Networks
and Health Insurance Coverage ................................................................................... 62
Table 4.4. Effects of Health Discussion Networks on Health Insurance Coverage...................... 63
Table 4.5. Effects of Health Discussion Networks on Health Insurance Coverage
(Without Perceptions of Health Insurance) .................................................................. 65

iv
LIST OF FIGURES
Figure 2.1. Perceptions of Health Insurance (A) and Healthcare Services (B) in Korea
and the U.S. ................................................................................................................. 17
Figure 2.2. Perceptions of U.S. Health Insurance Among Korean Immigrants with and
Without Pre-migration Experience of Korean National Health Insurance (KNHI) ... 17

v
ABSTRACT
Objective. To understand the socio-cultural influences on health insurance coverage among non-
elderly Korean Americans in California (26 – 64 years), focusing on perceptions of health
insurance and social networks, three studies were conducted. Their aims were as follow: 1) to
explore how Korean Americans perceive healthcare systems in the U.S. and Korea and how the
perceptions affect their intention to purchase health insurance plans; 2) to examine the association
between perceptions of U.S. health insurance and insurance coverage among Korean Americans;
and 3) to examine the effects of social networks on health insurance coverage among Korean
Americans.
Methods. For the first study, qualitative data were collected in 2015 through in-depth interviews
with 24 self-employed Korean Americans, living in the Greater Los Angeles area. Participants
were asked a set of open-ended questions that explored perceived experiences of health care in
the United States and Korea, respectively. Interviews were analyzed using an inductive thematic
content analysis rooted in Grounded Theory. For the second and third studies, primary survey
data were collected in 2018 through Korean community churches located in the Greater Los
Angeles area. A total of 549 non-elderly Korean Americans completed a self-administered
survey questionnaire inquiring about their perceptions and experiences regarding health
insurance and health care services in the United States. Ego-centric network data were also
collected through a name generator. Participants (egos) were asked to identify up to five people
(alters) with whom the respondents talk about health issues. Several characteristics about the
alters including topic of information that the respondents obtained from each alter (e.g. health
insurance) and levels of satisfaction with the information were also inquired. For the second
study, perceptions of health insurance were measured by levels of overall satisfaction with U.S.
vi
health insurance on a 5 point-Likert scale item. For the third study, sizes of social networks for
health information, including insurance-related information, were measured by counting the
number of alters with whom respondents talk specifically about health issues (i.e. health
insurance). Levels of satisfaction with the health information obtained from network members
were also be taken into account for the network effects, controlling for demographic
characteristics (age, gender, marital status), socio-economic status (household income, education,
employment), immigration status (years of residence in the United States, citizenship, English
proficiency), and health status (self-rated health, chronic illnesses) factors. The dependent
variable was health insurance status, dichotomized into two categories (1 = being currently
insured vs. 0 = uninsured). Multivariate logistic regression models were conducted to examine
whether positive perceptions of health insurance and the size of social networks for insurance-
related information are associated with health insurance coverage, respectively. In the third
study, perceptions of U.S. health insurance were included as a covariate in addition to the set of
covariates used in the second study, due to the potential confounding effects both on sizes of the
social networks for insurance-related information and health insurance coverage.
Results. In the first study, respondents complained about U.S. health insurance with respect to
cost, benefits, simplicity, and accessibility, by referencing their pre-migration healthcare
experiences in Korea. On the other hand, respondents who immigrated to the U.S. in the early
1980s when Korean universal health insurance system was not established, showed significantly
higher levels of satisfaction with U.S. health insurance and maintained health insurance for
substantial periods of time. In the second study, positive perceptions of health insurance were
positive associated with health insurance coverage. In the third study, sizes of social networks
where respondents talk about health issues had positive effects on being insured. The social
vii
network effects were larger when the topic of conversation was limited to health insurance and
the information obtained from personal networks was perceived to be satisfying. Perceptions of
health insurance weakened the association between social networks and insurance coverage.
Conclusion. The three studies comprising this dissertation represent the first empirical effort to
qualitatively and quantitatively reveal the effects of socio-cultural determinants of health care
access among Korean Americans. Health insurance coverage among Korean Americans is
influenced by diverse socio-cultural factors including pre-migration health care experiences,
perceptions of health insurance, and social networks in the ethnic communities. Specifically, the
first study (qualitative study) showed that Korean Americans tend to evaluate health insurance in
the United States based on their pre-migration healthcare experiences in South Korea, which
would influence their decision to purchase health insurance. The second study (quantitative
study) supported the qualitative finding by revealing that perceptions of U.S. health insurance are
associated with health insurance coverage among Korean Americans. In addition, the third study
(social network study) suggested a possibility that the decision to purchase health insurance
could be influenced by members in personal health discussion networks where Korean
Americans share information about health insurance. The findings of the study will be a critical
foundation to develop culturally competent interventions for Korean Americans to facilitate the
process of adjustment to the U.S. health care system. Particularly, when educating Korean
Americans in regard to health insurance enrollment, it is important for health social workers to
consider not only economic factors but also cultural and contextual factors including clients’
perceptions of health insurance and their personal health discussion networks as determinants of
health insurance status.

viii
Keywords: Pre-migration experience; perceptions of health insurance; social networks; socio-
cultural determinants; health insurance; Korean Americans;

Committee.
Lawrence A. Palinkas, Ph.D. (Chair)
Jungeun Olivia Lee, Ph.D. (Co-Chair)
Thomas Valente, Ph.D.

Funding.
The project described was supported by a pilot research grant from the Hamovitch Center for
Science in the Human Services at the USC Suzanne Dworak-Peck School of Social Work (grant
number: not applicable).
1
CHAPTER 1: INTRODUCTION
Background and Significance
Korean Americans in the U.S.
After the Immigration and Naturalization Act of 1965 abolished the restriction of
immigration from Asian countries, the number of Korean immigrants in the United States
increased dramatically between the 1970s and the 1990s (Min, 2011). According to the U.S.
Census Bureau, the Korean American population rapidly grew sevenfold from 38,711 in 1970 to
289,885 in 1980, and almost doubled to 568,397 in 1990 (Gibson & Jung, 2006). During that
period, Korea was the third largest source of immigrants to the United States, following Mexico
and the Philippines (Min, 2011). Although the influx of Korean immigrants gradually decreased
in the 1990s and the 2000s, the population of Korean Americans reached 1.1 million in 2010 and
reached approximately 1.9 million in 2018 (U.S. Census Bureau, 2018a). Among the total
Korean American population, about 55% were foreign-born Korean Americans (U.S. Census
Bureau, 2018b). According to the American Community Survey 2010-2015, almost one-third of
all Korean immigrants resided in California (31%), followed by New York (9%), and New
Jersey (7%) (O’Connor & Batalova, 2019). Korean Americans had a higher rate of educational
attainment than did the overall American population. In 2015, more than half (53%) of Korean
Americans (52% foreign-born and 60% U.S.-born) had a bachelor’s degree or higher, compared
to less than a third (30%) of the overall American population (Pew Research Center, 2017).
Korean Americans had higher incomes than the total population in the United States. According
to 2016 U.S. Census Bureau, the median household income of Korean Americans was $63,677,
compared to $57,617 for the total population. In terms of English proficiency, 75.2% spoke
2
languages other than English, and 41.4% of Korean Americans responded that they spoke
English less than “very well” (U.S. Census Bureau, 2016).
Health Insurance Coverage of Korean Americans
Despite their high educational attainments and economic success, the health literature has
consistently reported that Korean Americans are less likely than other racial/ethnic minority
groups to have health insurance (Carrasquillo, Carrasquillo, & Shea, 2000; Huang & Carrasquillo,
2008; Kao, 2010; Nguyen, Choi, & Park, 2015; Shin, Song, Kim, & Probst, 2005). According to
Current Population Survey (CPS) in 2006, 29.8% of Korean Americans did not have health
insurance, compared to 16.8% of Chinese Americans and 21.5% of Vietnamese Americans (Huang
& Carrasquillo, 2008). A study using California Health Interview Survey data reported that 36.1%
of Korean Americans aged 18-64 in California were uninsured compared to 15.1% of Chinese
Americans, 20.7% of Vietnamese Americans, and 6.9% of Japanese Americans (Kao, 2010). The
uninsurance rates among Korean Americans residing in ethnic enclaves were even worse. The
Korean Health Education, Information, and Research (KHEIR) Center conducted a survey in 1999
with randomly selected 1,660 Korean Americans living in Los Angeles County, reporting that
almost half of the non-elderly Korean Americans under aged 65 (48.7%) did not have health
insurance (Shin et al., 2005). A recent study reported that even after the implementation of the
Affordable Care Act (ACA), Korean Americans have maintained the lowest rates of insurance
coverage among Asian Americans (Park et al., 2018).
The lack of health insurance can negatively impact access to, and use of, healthcare, and
eventually, the overall health outcomes (Cook, Tseng, Chin, John, & Chung, 2014; Danis, Linde-
Zwirble, Astor, Lidicker, & Angus, 2006; Derose, Escarce, & Lurie, 2007; Franks, Clancy, & Gold,
1993; McWilliams, 2009; Ryu, Young, & Park, 2001; Weissman, Gatsonis, & Epstein, 1992;
3
Wilper et al., 2009). Empirical evidence supports that the lack of health insurance among Korean
immigrants often results in the delay of primary care and the underuse of preventive care (Choi,
2013; Ryu et al., 2001; Shin et al., 2005). Ryu and her colleagues (2001) examined the association
between health insurance and use of health services among 345 Korean Americans using the 1992
National Health Interview Survey (NHIS) and concluded that health insurance coverage was the
strongest predictor of use of health services among Korean Americans (Ryu et al., 2001). A similar
result was found in the study conducted by KHEIR that age, self-rated health, and health insurance
were the most influential factors on the frequency of doctor visits (Shin et al., 2005). Subsequently,
the lower rate of health insurance coverage among Korean Americans should be considered as a
critical public health issue. However, the reasons for this lower rate are poorly understood.
Socio-cultural Determinants of Health Insurance Coverage
Health insurance coverage among immigrants is associated with various factors, including
income (Jenkins, Le, McPhee, Stewart, & Ha, 1996; Shin et al., 2005), educational attainment
(Ryu et al., 2001), employment type (Brown, Ojeda, Wyn, & Levan, 2000; Huang & Carrasquillo,
2008; Kao, 2010), citizenship status (Carrasquillo et al., 2000; Huang & Carrasquillo, 2008),
length of stay in the U.S. (Thamer, Richard, Casebeer, & Ray, 1997), country of origin
(Carrasquillo et al., 2000), limited English proficiency (Cook et al., 2014), and health status (Ryu
et al., 2001). Specifically, Korean Americans with more educational attainment, higher family
income, smaller family sizes, and employment in either the public or private sectors, were more
likely to have health insurance (Ryu et al., 2001).
Among the diverse determinants of health insurance coverage, a conspicuously larger
proportion of self-employed Korean Americans, compared to other ethnic groups, has been
thought to cause Koreans Americans to be predominantly uninsured (Brown et al., 2000; Fairlie
4
& Meyer, 1996; Huang & Carrasquillo, 2008; Nguyen et al., 2015; Ryu et al., 2001; Shin et al.,
2005; Smolka, Multack, & Figueiredo, 2012; Van Tubergen, 2005). Access to affordable health
insurance in the U.S. heavily relies on one’s employment status, because the U.S. health insurance
system largely depends on employer-sponsored health insurance (Bilheimer & Colby, 2001; Davis
& Branscome, 2011b; Lieberthal, 2016; Smolka et al., 2012). Current Population Surveys (CPS)
reported that only 48% of Korean Americans were covered by employer-sponsored health
insurance, compared to 73% of American of European descent, 77% of Japanese Americans, 67%
of Chinese Americans, and 74% of Filipino Americans (Brown et al., 2000). However, even after
adjusting for the array of other influential factors, including employment status and type of
employment (Cook et al., 2014; Kao, 2010), the gaps in health insurance coverage between Korean
Americans and other ethnic groups still remain unexplained. A study examining how health
insurance coverage can vary by ethnicity and employment type showed that Korean Americans
had the lowest rates of health insurance among Asian Americans regardless of the employment
type including private/public sectors, self-employed, and not working family business (Nguyen et
al., 2015).
A possible explanation for the unexplained disparities in health insurance coverage across
ethnic groups lies within the socio-cultural factors that are unique to each group (Nguyen et al.,
2015). Recently, the health literature has focused on the roles of culture and social contexts in
access to health care and use of health services (Abel, 2008; Alegría, Pescosolido, Williams, &
Canino, 2011; Macintyre, Ellaway, & Cummins, 2002; Napier et al., 2014). The experience of
receiving health care from systems in the countries of origin, for example, may affect patterns of
utilization of health care systems in the host country (Anderson, 2008). The values and norms
related to health care among immigrants may be more tied to cultural patterns found in their
5
countries of origin than to the cultural systems of the host country. In other words, immigrants
would bring with them culturally determined beliefs, values, and attitudes that guide their decisions
as to how and when to use health services. These beliefs, values, and attitudes may differ from
those which are grounded in the health care systems of the host country, leading to maladaptive
patterns of health services utilization (Abel, 2008; Ajzen, 1991; Anderson, 2008). In the same vein,
Korean Americans may have had prior experience with access to, and use of, healthcare services
in Korea that gave rise to unique norms and values, which affected their perceptions and attitudes
with respect to the American healthcare system. For instance, Korean Americans who are familiar
with Korean National Health Insurance (KNHI), which provides a universal coverage though a
single-payer system, might have culturally embedded beliefs and values of health insurance that a
universal single-payer health insurance system is more desired than a market-based health
insurance system despite limited choice of insurance plans. The perceptions may lead to negative
attitudes towards U.S. health insurance, which, consequently, may affect Koreans’ decision-
making to purchase health insurance plans in the U.S. These perspectives may offer a better
explanation for the paradox of well-educated Korean Americans who are less likely to have health
insurance than other immigrants as well as native-born Americans (Alegría et al., 2006; Anderson,
2008; Nguyen et al., 2015; Owen, 2009; Ryu et al., 2001).
Another possible mechanism for this pattern of insurance underutilization among Korean
Americans lies in culturally embedded health beliefs and health behaviors that are reinforced by
social interactions (Abel, 2008; Gerbert, Sumser, & Maguire, 1991; McLean, 2017; Oh & Jeong,
2017). In general, social networks can affect individuals’ health-related behaviors through at least
three plausible pathways: (1) diffusing health information or encouraging adoption of healthy
norms of behavior/controlling deviant health behaviors, (2) increasing access to healthcare
6
services and facilities, and (3) enhancing psychosocial processes of coping and adaptation
(Kawachi & Berkman, 2000). It is also plausible that ethnic social networks can reinforce the
negative beliefs and values about healthcare access and utilization in the U.S. that Korean
Americans might have, which could result in the decision not to purchase or use health insurance
(Hyunsung Oh & Chung Hyeon Jeong, 2017). Social networks may exert both a positive and a
negative influence on health insurance coverage in this subpopulation. However, little is known
about whether and how the social networks of Korean Americans influence the persistence of such
cultural resources and, in turn, affect the health behaviors specifically related to health insurance
purchase.
Specific Aims
To fill these gaps in the literature, the dissertation has the following specific aims:
Aim 1: to explore how Korean Americans perceive healthcare systems in the U.S. and Korea and
how the perceptions affect their intention to purchase health insurance plans;
Aim 2: to examine the association between perceptions of U.S. health insurance and insurance
coverage among Korean Americans;
Aim 3: to examine the effects of social networks on health insurance coverage among Korean
Americans.

7
CHAPTER 2: MANUSCRIPT 1
“Understanding Perceptions of U.S. and Korean Healthcare Systems Among Self-employed
Korean Immigrants and Their Health Insurance Purchase: A Qualitative Study”

Abstract
Objective. Korean Americans in the United States (U.S.) are more likely to be uninsured despite
their higher education and economic prosperity than other Asian ethnic groups, a condition
largely unexplained in analyses adjusting for socioeconomic factors. This study explored how
pre-migration healthcare experiences of Korean Americans shape their perceptions of healthcare
system in the U.S. and, eventually, affect the decision to purchase health insurance.
Methods. We conducted in-depth interviews from March to June 2015 with 24 self-employed
Korean immigrants living in the Greater Los Angeles, who were mostly uninsured prior to
implementation of the Affordable Care Act (ACA). Participants were asked to describe their
perceived experiences of health insurance and health services in the U.S. and Korea,
respectively. Interviews were transcribed verbatim, thematically coded, and analyzed using the
constant comparative method.
Results. Respondents often complained about U.S. health insurance with respect to cost,
benefits, simplicity, and accessibility, by referencing their pre-migration healthcare experiences
in Korea. On the other hand, Koreans who migrated to the U.S. in the early 1980s when the
Korean universal health insurance system was not established, expressed satisfaction with U.S.
health insurance and maintained health insurance for substantial periods of time.
Conclusions. These findings highlight the significance of pre-migration healthcare experiences
as a critical cultural determinant of healthcare when newly attempting to meet their healthcare
8
needs in the U.S healthcare system. Health interventions and policies targeting immigrants
should attend to pre-migration healthcare experiences to gain a fuller picture of norms and
beliefs about healthcare and health insurance.

Keywords: Pre-migration experience; socio-cultural factors; Korean immigrants; health
insurance; adaptation; healthcare system

9
Understanding Perceptions of U.S. and Korean Healthcare Systems Among Self-employed
Korean Immigrants and Their Health Insurance Purchase: A Qualitative Study

Introduction
Korean Americans are likely to be uninsured when compared to other racial/ethnic
groups (Carrasquillo et al., 2000; Huang & Carrasquillo, 2008; Kao, 2010; Nguyen et al., 2015).
Such findings have puzzled many experts because Korean Americans tend to have higher
education and income than most racial and ethnic groups; and these factors are fairly robust
predictors for the likelihood of having health insurance (Kao, 2010; Nguyen et al., 2015). A
study using 2009 California Health Interview Study (CHIS) data reported that Korean Americans
had higher uninsured rates (39.5%) than their Chinese (16.6%) and Vietnamese (11.7%)
counterparts while Korean Americans reported approximately 40% higher high school and
higher educational attainment when compared to Vietnamese Americans (Nguyen et al., 2015).
A recent study discovered that Korean Americans’ uninsured rates dropped by 11.3% after
implementation of the Patient Protection and Affordable Care Act (ACA); yet, they were still the
most likely to be uninsured among Asian American ethnic groups (Park et al., 2018).
Literature has pinpointed higher rates of self-employment among Korean Americans as a
factor that explains the higher uninsured rates among Korean Americans (Brown et al., 2000;
Huang & Carrasquillo, 2008; Nguyen et al., 2015), given access to affordable health insurance in
the U.S. largely relies on employment-based health benefits (Bilheimer & Colby, 2001; Davis &
Branscome, 2011; Lieberthal, 2016). One study revealed that Korean immigrants had
conspicuously higher uninsured rates and lower rates of employer-sponsored health insurance
coverage compared to other immigrant groups (Carrasquillo et al., 2000). Specifically, more than
10
one-third of Korean immigrants (35%) were uninsured, while other immigrant groups from
western countries including Canada (10%) Germany (7%), England (20%), and even Asian
countries including China (20%) and the Philippines (20%) were relatively less uninsured. On
the other hand, only 53% of Korean immigrants were covered by employer-sponsored health
insurance, whereas the majority of other immigrants from Canada (87%), Germany (75%),
England (74%), and China (74%) were covered by employer-sponsored health insurance
(Carrasquillo et al., 2000). Korean Americans’ disproportionate health insurance coverage,
however, still remains unexplained even after adjusting for the array of other influential factors
including employment status and type of employment (Cook et al., 2014; Kao, 2010). Cook et al.
(2014) analyzed pooled 2005–2012 CHIS data to discover the uninsured rate of Korean
Americans working in small businesses: They were 6.21 times more likely to be uninsured when
compared to Japanese Americans even if self-employed status and other known confounding
factors (e.g., education) were adjusted in statistical models. Another study examining how health
insurance coverage can vary by employment and ethnicity also discovered that Korean
Americans had the lowest insured rates among Asian Americans across all employment sectors
(Nguyen et al., 2015).
We believe that such disparities in health insurance coverage might be explained by
socio-cultural factors that construct ethnicity-specific cultural experiences and institutions
(Alegría, Atkins, Farmer, Slaton, & Stelk, 2010; Alegría et al., 2011). One of the potential socio-
cultural factors is the remarkably different healthcare systems in Korea and the U.S. Previous
immigration literature indicated that immigrants’ perceptions and behaviors related to health care
in the host countries are strongly influenced by sociocultural referents and pre-migration
experience (Leduc & Proulx, 2004; Portes, Kyle, & Eaton, 1992). Nguyen et al. (2015) suggested
11
that Korean immigrants might have lower willingness to pay high insurance premium in the U.S.
if they were accustomed to Korean universal health insurance, which is relatively cheap and
simple compared to U.S. health insurance. South Korea established the Korean National Health
Insurance program (KNHI), a single-payer governmental health insurance, for a relatively short
period of time (Jones, 2010). After the first government-led health insurance was mandated for
large companies’ workers in 1977, it took only 12 years until every person was mandated in
1989 to pay premiums to the governmental health insurance plan (Jeong, 2011; Song, 2009). To
avoid citizens’ dissent in response to increased payroll tax for funding the KNHI, the
government has stuck to a lower premium, coupled with limited benefits coverage, resulting in
patients’ share mounting when they are treated for illnesses requiring intensive care (Jones,
2010). According to a recent report (OECD, 2017), out-of-pocket medical expenditure in South
Korea accounts for 5.1% of total household consumption, double the U.S. average (2.5%).
Because the KNHI is a single payer that negotiates with many healthcare providers, healthcare
cost inflation has been effectively controlled (Song, 2009). The single-payer system provides the
KNHI, as a monopolistic buyer of health services, more bargaining power in negotiating medical
fees with health providers (Jones, 2010). To avoid political resistance from a majority of the
population, the KNHI has suppressed the out-of-pocket amount patients pay for outpatient care,
and many healthy people in South Korea are satisfied with the KNHI, at least until they need
intensive care due to very serious illnesses or injuries (Lee, Chun, Lee, & Seo, 2008; Song,
2009). Since the single-insurer KNHI has very simple rules, patients do not have to deal with
administrative complexities that subscribers to health insurance in the U.S. often encounter. For
instance, there are no in-network or out-of-network providers in South Korea because every
healthcare provider is legally mandated to accept every citizen, all inevitably covered by the
12
KNHI. Patients do not need to take any action to obtain or renew KNHI coverage, which is
hardly the case in the U.S.
As Ronald Anderson (2008) argued that features of a macro-level healthcare system
affect individual-level behaviors in regard to healthcare usage, notable system-level differences
that Korean immigrants face can create the discomfort and fear that arise from confusion when
seeking care in the U.S. Immigrants bring beliefs, values, and attitudes from their previous
interaction with institutions in their home country; and those existing norms related to healthcare
services and health insurance may influence their decisions as to how and when to use health
services (Abel, 2008). Korean Americans, particularly recent migrants, may have norms that
differ from those grounded in the U.S. healthcare system, leading to maladaptive patterns of
healthcare usage. However, most studies about influences of immigrants’ pre-migration
experience on adaptation to host countries have focused mainly on mental health issues (Li,
2016; Li & Anderson, 2016; Mähönen & Jasinskaja-Lahti, 2013; Trieu, 2013); little research has
been conducted on the potential association between pre-migration experience of the home
country’s healthcare system and adaptation to that of the host country. A qualitative study
conducted in Hawaii discovered that differences in the health insurance system between Korea
and the U.S. challenged Korean immigrants seeking healthcare (Choi, 2013). The study,
however, did not include behaviors related to purchasing health insurance but mainly focused on
healthcare usage. To fill the gap, this study explored how pre-migration experiences with the
Korean healthcare system among self-employed Korean immigrants affected their decision to
purchase health insurance in the U.S. Understanding potential influences of cultural factors
(beliefs, norms, etc.) of ethnic minorities on their access to healthcare, perhaps associated with
13
pre-migration experience of home country healthcare systems, will help us reduce existing
healthcare disparities among immigrants, particularly given current U.S. healthcare reform.
Methods
Data
This study used qualitative data from in-depth individual interviews with 24 self-
employed Korean immigrants living in the Greater Los Angeles area. Respondents were invited
to an hour-long interview if they met eligibility criteria, including: 1) speaking Korean as their
primary language and 2) being self-employed for an extensive period. This particular group was
considered to be informative with respect to the influences of non-economic factors on health
insurance purchase because they had fewer financial incentives to purchase health insurance
compared to those who usually obtain health insurance through employment. Respondents were
recruited through purposive sampling, considering covering a variety of social spaces where the
study population’s members are likely to locate. In addition to the snow-ball approach (to contact
the next potential respondent through a study respondent), we also used local Korean ethnic
churches to find respondents who met the eligibility criteria and who could offer lived
experiences, possibly not discovered through previous interviews.
Table 2.1 provides demographic information about the 24 respondents, suggesting that
our efforts to recruit respondents from diverse backgrounds, including gender, age, types of
occupation, length of residence in the U.S., and insurance status, seemed successful.
Respondents were 50% male and female, respectively, and the mean age was 50.7 years. In
regard to businesses in which respondents were currently working, or, if retired, had previously
worked, a wide range of occupations were included. Seven respondents had health insurance
after migration to the U.S. before the ACA’s individual mandate and were covered by their
14
spouse’s employment-based health insurance or had health insurance mandated for international
students during university study. Over half (62.5%) reported that they obtained health insurance
through the ACA’s Marketplace or expanded Medi-Cal, which is California’s Medicaid program.
In contrast, four respondents were still uninsured even after the ACA individual mandate took
effect on January 1, 2014. Their average years of residence in the U.S. was 18.7 (SD = 9.1
years). In regard to experience of health insurance or healthcare services in South Korea, four
respondents refused to respond because they had either migrated to the U.S. before
implementation of the KNHI (e.g., ID#3) or they did not remember their health insurance in
South Korea. As for their experiences with health insurance and healthcare services in the U.S., a
few respondents refused to respond because they had not had any experience with either system.
In-depth individual interviews were conducted from March to June 2015. The average
interview length was 63 minutes, ranging from 34 to 96 minutes. All respondents completed
informed consent. Because respondents said that they would be more comfortable speaking
Korean, all interviews were conducted in Korean, transcribed in Korean, and then translated into
English. Individual semi-structured interviews were conducted with a set of questions to explore
pre/post-migration experiences using health insurance and healthcare in South Korea and the
U.S., respectively, as well as barriers to and facilitators of access to healthcare in the U.S (the
interview guide is available in Appendix A). Respondents were asked to rate 1) health insurance
and 2) healthcare services in both Korea and in the U.S. on a scale of 1–10, reflecting their
overall perceptions of the healthcare systems in these countries (10 being the most positive).
Analysis
We used the constant comparative method rooted in Grounded Theory (Corbin & Strauss,
2008; Creswell, 2013) to explore the roles of pre-migratory healthcare experience in purchasing
15
health insurance. Two researchers conducted independent open coding to identify concepts and
develop higher-level concepts, incorporating those that emerged during the interviews (Corbin &
Strauss, 2008). From independent open coding, the researchers discovered separate lists of codes
and categories relevant to our research question. The researchers compared, matched, and
discussed codes and categories derived from independent open coding and reached consensus via
thorough discussion. This process led to agreement on which codes and categories should be
reported in our manuscript. To ensure those codes were well reflected in the transcripts, both
authors reviewed respondent texts for confirmation. In addition to qualitative data, we compared
the levels of positive perceptions of health insurance and healthcare services that respondents
reported as referencing South Korea or the U.S. The rejection level for a significance test was
0.05. Analyses were conducted using STATA 15.1.
Results
Quantitative Findings
Figure 2.1 presents variously favorable perceptions of health insurance and healthcare
services in the U.S. and Korea. Respondents perceived Korean health insurance significantly
more positively (M = 8.2, SD = 1.7) than they did U.S. health insurance (M = 4.7, SD = 2.4) (t =
−5.78, p <.001). With respect to healthcare services, respondents reported slightly higher scores
for Korean healthcare services (M = 7.5, SD = 1.5) than U.S. healthcare services (M = 6.7, SD =
1.9), but the differences were not statistically significant. Interestingly, those who migrated to the
U.S. in the early 1980s before the KNHI system was fully established, rated the U.S. health
insurance more positively and had maintained health insurance for substantial periods prior to
ACA implementation (Table 2.1). Differences in scores for U.S. health insurance between
respondents who had had experience with the KNHI (M = 3.9, SD = 1.9, n = 20) and their

Table 2.1. Demographic Characteristics of Sample and Overall Perceptions with Healthcare Systems in the U.S. and Korea
ID Gender Age
Household
income
(monthly)
Occupation
Insurance
Type
Year of
Enrollment
Years of
residence
in U.S.
Perceptions of Healthcare Systemsa
Health
Insurance
Healthcare
Services
Korea U.S. Korea U.S.
1 Female 53 NR flower shop ACA 2013 26 9 5 7 8
2 Male 55 $5,000 coin laundry ACA 2014 25 6.5 5 N/A 7
3 Female 62 $4,000 auto body part sales ACA 2013 34 N/A 9 7 6.5
4 Male 38 $8,000 acupuncturist ACA 2013 8 10 3.4 4 8
5 Male 39 $8,500 manufacturer ACA 2013 9 7.5 3 8 5
6 Male 42 $5,500 auto body part sales ACA 2014 10 8 3.5 8 5
7 Female 42 $9,000 martial arts ACA 2014 13 10 2.5 7.5 7
8 Male 49 $3,500 pastor ACA
2002–2012;
2014
18 8.5 NR 6.5 6.5
9 Male 57 $3,500 flower shop ACA 2013 12 10 4 9 6
10 Male 48 NR retailer Medi-Cal (ACA) 2015 9 9 3.5 9 8.5
11 Female 54 $6,000 laundry shop Medi-Cal (ACA) 2004–2008 19 7 NR 8.5 NR
12 Female 52 $2,000 childcare Medi-Cal (ACA) 2014 12 10 5 9.5 5
13 Female 66 $2,500 sewing Medi-Cal (ACA)
1983–2007;
2014
38 N/A 8.5 6.5 7.5
14 Male 50 $7,000 acupuncturist Medi-Cal (ACA) 2014 8 5 3 8 10
15 Male 31 $5,000 car sales Medi-Cal
2006; 2008;
2012
9 7 7.5 7.5 NR
16 Female 59 $4,000 trade business private 1993 20 N/A 8 8 8
17 Female 60 $7,000 structural design private 1995 32 6 4.5 8 7.5
18 Male 52 $2,000 martial art private 2005 26 9 3 NR 7.5
19 Male 33 $6,500 pastor private 2006 22 N/A 6 N/A 8
20 Male 60 $7,500 gas station cost-sharing 2014 33 5 7.5 9 7.5
21 Female 35 $9,000 baby photo studio N/A never 15 10 N/A 10 2
22 Male 56 $3,000 acupuncturist N/A never 19 9 1 6 3
23 Female 58 NR laundry shop N/A never 13 7 NR 7 NR
24 Female 50 $10,000 laundry shop N/A never 18 9.5 1 4.5 7
Note. a. perceptions of healthcare systems: higher scores mean more positive perceptions; NR = not reported; N/A = not applicable;
16

17
Figure 2.1. Perceptions of Health Insurance (A) and Healthcare Services (B) in Korea and the
U.S.

Note. *** p < 0.001; higher scores mean more positive perceptions; KOR = Korea, US = United States

Figure 2.2. Perceptions of U.S. Health Insurance Among Korean Immigrants with and Without
Pre-migration Experience of Korean National Health Insurance (KNHI)

Note. *** p < 0.001; higher scores mean more positive perceptions; Yes = respondents with KNHI experience, No =
respondents without KNHI experience

***
***
A B

18
counterparts without experience with the KNHI (M = 7.9, SD = 1.3, n = 4) were statistically
significant (t = 4.00, p <.001) (Figure 2.2).
Qualitative Findings
The Korean healthcare system as a reference
Most respondents who experienced the Korean healthcare system tended to use it as a
standard to evaluate the U.S. system. One interviewee (ID#1, female, 53yrs, flower shop) stated:
“I think Korea has really well-maintained health insurance. So, anytime, I tend to compare with
the one I have in the U.S.” Respondents had negative perceptions of U.S. health insurance (e.g.,
too high a deductible before the insurance company starts to pay) when they systematically
compared the benefit rules they used in South Korea with those of the U.S. When a respondent
was asked to describe his interaction with health insurance companies since his migration, he
answered:
I am not sure whether health insurance in the U.S. has any positive aspects. Whenever I
tried to find any benefits better than Korean health insurance, I could not find one. Um, I
do not think there is one, a positive point. (ID#5, male, 39 years, manufacture)

Korean immigrants generally perceived Korean health insurance as superior to U.S.
health insurance in terms of cost, benefits, simplicity, and accessibility.
Cost
Respondents perceived healthcare cost, including premium and out-of-pocket payments
in the U.S., as much more expensive than in Korea, and such perception appears critical when
they decide not to purchase private health insurance. One respondent who had never had health
insurance pointed out that healthcare cost in the U.S. exceeded their expectation, which
referenced the amount they had paid in Korea.
The first reason why I could not enroll in health insurance after we moved to America
was that it is too expensive here. When we first came to the U.S. from Korea, we expected

19
it would be about several 10 dollars at most. But when we moved here, the premium
increased around several hundred dollars, so we could not enroll. (ID#23, female, 58
years, laundry shop)

Benefits
A few respondents were aware of the limited coverage that they could use if living in
Korea. One respondent, whose wife was hospitalized for about 2 months due to toxic hepatitis
prior to migration to the U.S., mentioned:
I guess one negative I can think of [in Korean health insurance] is that a serious illness
needing intensive care is not sufficiently covered by the plan although small health issues
are treated quickly and without a cost concern. It is different here in the U.S. where care
is provided if someone needs [it] regardless of cost. (ID#10, male, 48 years, retailer)

On the other hand, most respondents believed that benefits of health insurance they had
before migration were better than those in the U.S. Even though some of the respondents were
aware of limited benefits of Korean health insurance for serious illnesses, they still had positive
views about Korean health insurance that they had witnessed during pre-migration periods.
[By paying an insurance premium,] I should be entitled to receive services as much as I
paid for. … I think there are so many treatments not covered by health insurance in the
U.S. In Korea, a really serious disease, even an incurable disease is eligible for
coverage, not a lot though. But still, it is covered. But over here [in the U.S.], if you
actually visit [hospitals], there are so many things that are not covered. (ID#6, male, 41
years, auto body part retailer)

Simplicity
Interviewees perceived insurance plans in the U.S. as too complicated, resulting in
inability to understand their offerings. As opposed to the simplicity of the single-payer system in
South Korea, respondents expressed agony over too many options when buying health insurance
in the U.S. One respondent, who was not accustomed to selecting health insurance plans,
complained about the difficulty of finding and applying for suitable health insurance plans.
In Korea, everything is governed and run by the government. Since there is a
government-run agency, there will always be standards. […] The system itself is very

20
fair. On the other hand, the system here in the U.S. is personal and private. You need to
do your own research and apply for plans appropriate for you. That is really hard; it is
not easy at all. There are no standards. (ID#9, male, 57 years, flower shop)

Furthermore, limited English proficiency among Korean immigrants is a relevant barrier
to finding adequate health insurance plans. Respondents were not able to understand written
documents that explain each insurance plan’s specifics.
There are many types of insurance here. […] Language is another issue. It is also really
tough for me to look it up by myself by reading really thick booklet in English. (ID#6,
male, 41 years, auto body part retailer)

Accessibility
Respondents commonly cited confusion about access to outpatient care. In Korea,
patients are not required to make an appointment to visit a doctor’s office for care. Patients also
have discretion to visit any specialists without referrals from primary care providers. In contrast,
patients in the U.S. have to follow varying rules depending on their health insurance coverage for
a referral when seeking care from a specialist provider. In the eyes of self-employed Korean
immigrants, such a system appears inconvenient and time-consuming, and they feel discomfort
dealing with strange rules that eventually discourage access to needed care.
For HMO, we have to choose a primary care physician and go see him [whenever we
need care] … requiring referrals to seek care from a hospital. So, the whole process
takes forever. […] But in Korea, if you want to go to any hospitals, you can just go there.
(ID#9, male, 57 years, flower shop)

Out-of-pocket costs in the U.S., which were perceived by respondents relatively more
expensive, was another barrier to access. Despite being covered by insurance, respondents did
not frequently use health services in the U.S. as much as in Korea due to the concern about too
expensive copays or coinsurance. Thus, they eventually dropped their health coverage by not
paying the premium.

21
In Korea, if you have your insurance card, you can go to any hospital. Even though there
is co-payment, it only costs 1 or 2 dollars. It is like you get your service almost for free.
When you go to a polyclinic or go to a small, local hospital, you can just go without any
difficulties [regarding cost]. That was really convenient. (ID#1, female, 53 years, flower
shop)

Perception of U.S. health insurance: “It’s a waste of money.”
Self-employed Korean immigrants mentioned the high cost, yet limited or poor insurance
benefits of U.S. health insurance, compared to their pre-migration insurance, as the main force
discouraging health insurance purchase. A respondent who had a co-op plan with a fairly cheap
premium mentioned that his only reason for buying this co-op plan was to avoid the ACA’s
individual mandate penalty.
In the U.S., the amount of premium that a family has to pay for health insurance is too
much, and there are too many blind spots. As you know, many things are different,
compared to Korean insurance. Because of too much monthly payment, I could not even
think about enrolling. (ID#20, male, 60 years, gas station)

Respondents did not believe that insurance plans in the U.S. effectively support access to
care. They thought that U.S. plans are cost-inefficient, thus not worth purchase. This line of
thinking was often contrasted to levels of premium and out-of-pocket payment during pre-
migration in Korea. A respondent complained that there was no reason to purchase health
insurance in the U.S. if the costs and benefits were compared to the insurance he had before his
migration and before a recent visit to Korea. This respondent recently flew to Korea to have
medical care for an ailment.
If I pay something, I should earn something in return. But there is no such thing here in
the U.S. I have experienced that there is actually nothing that I could receive [by having
health insurance in the U.S.]. When I visited to Korea, […] there was nothing much that I
need to pay [for healthcare]. On the other hand, here in the U.S., even with insurance, it
is expensive. … So, why should I need health insurance? (ID#6, male, 41 years, auto
body part retailer)

22
Given their perception of health insurance’s poor cost-benefit ratio, respondents tended to
view buying health insurance as a waste of money. Respondents who had never had U.S. health
insurance felt that it was useless and paying for it was a waste of money.
Because I do not go to a hospital often, so I feel like I am wasting my money. I,
especially, go to a hospital once per year or not at all. Basically, I am throwing away
that money (ID#21, female, 35 years, baby photo studio).

The prevalent perception among self-employed Korean immigrants that buying health
insurance is not essential appears to influence their intention to keep health insurance when it is
not compulsory to have health insurance. A new enrollee in health insurance declared that he
would not maintain health insurance if the ACA individual mandate is abolished.
When I become old and have to go to a hospital often, if then, well I might go without
feeling it is wasteful. But now, I am still at an age of thinking it is not worth it. […] If
Obamacare comes to an end, and if there is no mandatory enrollment, I think I would
terminate it. (ID#5, male, 39 years, manufacturer)

Respondents indicated that the perceived necessity of health insurance may vary
according to individuals’ socio-cultural backgrounds. Depending on interactions with health
insurance and healthcare providers in the past, people have distinct ideas about what health
insurance should offer and cost. Korean immigrants may have distinct norms and beliefs toward
what health insurance should provide when compared to their racial and ethnic counterparts
because of different experiences regarding health insurance and healthcare in their countries of
origin.
I think other people in the U.S. are more sensitive than Korean immigrants in terms of
importance of health insurance. […] Being sensitive means that they have a perception
like “you must have health insurance.” Korean immigrants think it is a waste of money to
use money on unnecessary things [like health insurance in the U.S]. Other immigrant
groups may believe that money paid for health insurance should be spent anyway, instead
of thinking that it is a waste of money. That is the difference [between racial and ethnic
groups]. (ID#18, male, 52 years, martial art)

23
Such distinctive norms and notions in regard to health insurance exist even between
Korean- American generations. Korean Americans who were born and raised in the U.S. would
have different perceptions of health insurance from Korean immigrants who were raised and
socialized in Korea. One respondent mentioned:
People who were born here or migrated very early in their ages from Korea easily accept
culture here in the U.S., as it is the only culture they have experienced. But people just
like me, who migrated from Korea after the age of 30 and had used benefits of Korean
health insurance hate the health insurance over here. Koreans do not think the money
[for health insurance] is something that they should pay. They think they are wasting
their money. (ID#5, male, 39 years, manufacture)

Discussion
The present study explored potential influences of pre-migration experience among self-
employed Korean immigrants on current perceptions of health insurance and healthcare services
in the U.S and its consequences on health insurance purchase. Our findings demonstrated that
Korean immigrants had deeply rooted norms, images, and notions about health insurance,
seemingly learned and internalized from experiences with health policies of the single-payer
insurance in Korea. Respondents did not seem to have the capacity to contextualize cost and
benefits of health insurance as adjusted to the cost and generic perception shared by a majority of
people in the U.S. Immigrants’ perception of what health insurance should be does not seem to
match what actual health insurance plans in the U.S. offer. As with previous literature (Leduc &
Proulx, 2004; Portes et al., 1992), we discovered that immigrants’ pre-migration healthcare
experiences in the country of origin played a role as critical references in their interpretations of
the quality and degree of satisfaction with health insurance and health services. When seeking
care after buying health insurance because of the ACA’s individual mandate, many Korean
immigrants who migrated after the KNHI was implemented expressed discontent about
discouraging administrative rules and processes for seeking care by referencing previous

24
experiences during the pre-migration period. Apparently, such negative attitudes toward U.S.
health insurance appear to impede purchase of health insurance and to encourage them to rely on
prior coping strategies, even when they have acute symptoms, while uninsured (Choi, 2013; Oh
& Jeong, 2017). As a community, self-employed Korean immigrants have built a reservoir of
collective knowledge related to ethnic enclave health care that can be easily accessed through
Korean American social networks (Choi, 2013; Oh & Jeong, 2017).
Our findings suggest that high uninsured rates among Korean Americans are not only
triggered by individuals’ rationale for maximizing economic returns based on their own cost-
benefit analysis, but also driven by mismatch between what existing U.S. health insurance plans
offer and the norms, beliefs, and notions deeply rooted in community mentality about what
health insurance should offer. These group-level norms for health insurance can be largely
created from immigrants’ shared experiences during the pre-migration period. The mismatch
between the imaginary, ideal health insurance and actual health insurance available in the U.S.
seems exacerbated by self-employed Korean immigrants’ limited information. The same group
was found to be surrounded by ethnically and occupationally homogeneous social networks,
limiting the range of information related to health, health insurance, and providers (Oh & Jeong,
2017). One respondent said that he often had difficulty understanding the jargon, for instance
“HMO” and “PPO,” in the policy booklet, that those terms were confusing, and made him see
insurance as fruitless. Although California has over 1.5 million residents who identify
themselves as Korean and many of them use Korean as a primary language, our finding suggests
that we are not doing the best job to improve access to culturally appropriate health information
among Korean immigrants.

25
Noteworthy also is that individual perceptions of a healthcare system can be biased by
limited personal experiences and thus might not reflect the healthcare system’s objective
features. Despite the KNHI system’s higher out-of-pocket spending compared to the U.S.
system, a majority of respondents reported that co-payments in Korea were much cheaper than in
the U.S. Such a contradictory result seems attributable to the healthy immigrant effect (Kennedy,
Kidd, McDonald, & Biddle, 2015). It is plausible that relatively healthy Koreans migrated to the
U.S., that is, those generally satisfied with Korean health insurance due to lack of experience
with its negative aspects including limited benefits for serious illnesses. Pressured to select self-
employment by socio-structural barriers (Min, 1984), healthy Korean immigrants would take
U.S. health insurance’s negative aspects, mainly regarding cost issues, more seriously, resulting
in extremely lower levels of satisfaction with U.S. health insurance. That is, a certain group of
immigrants may encounter additional socio-cultural barriers than others. From this perspective, it
is critical to understand what socio-cultural barriers exist among immigrants during their
adaptation to a new healthcare system and how culturally determined values, norms, beliefs, and
customs affect adaptation as a coping mechanism for those barriers.
Several limitations of the present study related to methodological issues should be noted.
First, study findings cannot be generalized to the larger population of Korean immigrants
engaged in other types of employment or living in other residential areas. This study purposively
recruited respondents using specific inclusion criteria for employment and location, in order to
capture socio-cultural barriers to adaptation to the U.S. healthcare system among Korean
immigrants. Despite our efforts to encompass diverse Korean immigrants, interpretation of the
results should be limited to self-employed Korean immigrants residing in the Greater Los
Angeles area. Additionally, the study design with its qualitative approach does not allow us to

26
establish causal inferences between pre-migration experiences of healthcare systems in home
countries and specific behaviors related to healthcare access or healthcare use in host countries.
Despite these limitations, this study makes important contributions to the literature by
disclosing the possibility that immigrants’ pre-migration experience can affect their perceptions
of, attitudes toward, and behaviors in regard to host countries’ healthcare systems. With respect
to social work implications, this study suggests that it would be not enough to merely provide
health insurance information to ethnic minority groups including Korean immigrants to increase
their health insurance coverage. Social work health educators should consider that immigrant
groups may have culturally embedded beliefs and norms about health insurance, which can affect
health behaviors related to health insurance enrollment, and further, use of health insurance. In
addition, as a policy implication, the findings of this study suggest that the individual mandate of
the ACA needs to be maintained to increase, at least to retain, health insurance coverage among
self-employed Korean Americans.
Further research needs to examine how negative perceptions of and attitudes toward the
U.S. healthcare system actually affect Korean immigrants’ utilization of health insurance or
intention to hold health insurance in the context of recent U.S. healthcare reform. When we
consider the socio-cultural contexts in which individuals are situated, we can better explain and
predict individual behaviors with respect to health insurance coverage. More comprehensive
approaches are recommended to understand existing healthcare disparities among immigrants
with differing socio-cultural backgrounds.

27
CHAPTER 3: MANUSCRIPT 2
“Perceptions of Health Insurance and Health Insurance Coverage Among Korean Americans”

Abstract
Objective. This study investigates the association between positive perceptions of health
insurance and health insurance coverage among Korean Americans.
Methods. Using a purposive sampling method, a total of 549 non-elderly Korean Americans
aged between 26 and 64 were recruited from July to October in 2018 through Korean community
churches in the Greater Los Angeles area. Participants were asked to complete a self-
administered questionnaire assessing perceptions of health insurance in the U.S in regard to cost,
benefits, accessibility to health care providers, simplicity, access to information, awareness of
benefits, use of benefits, perceived necessity of health insurance for health care, and intention to
hold health insurance even if not mandatory. A multivariate logistic regression was used to
examine the association between positive perceptions of health insurance and health insurance
coverage among Korean Americans. Covariates included age, gender, marital status, household
size, household income, education, employment, citizenship, years of residence in the United
States, English proficiency, and health status.
Results. Among the study sample (n = 549), about 20% of the respondents were still uninsured.
Controlling for covariates, positive perceptions of health insurance were significantly associated
with currently being insured (OR = 2.8, 95% CI = 1.8 – 4.5).
Conclusion. The findings of the study revealed that individuals’ perceptions of health insurance
among Korean Americans were associated with health insurance coverage. The results call for
more in-depth research to investigate the associations between perceptions and insurance

28
enrollment. The results also underscore the importance of providing culturally tailored health
education for the uninsured Korean Americans. Specifically, more educational efforts to reshape
their perceptions of health insurance would be needed. Also, social work health educators should
consider possible influences of ethnic culture on the perceptions of health insurance.

Keywords: Perceptions of health insurance, health insurance coverage, Korean Americans

29
Perceptions of Health Insurance and Health Insurance Coverage Among Korean
Americans

Introduction
Disparities in health insurance coverage have been persistently documented for Korean
Americans. A study using California Health Interview Survey reported that Korean Americans
aged 18 - 64 in California were more likely to be uninsured (36.1%) compared to other Asian
Americans subgroups including Chinese (15.1%), Vietnamese (20.7%), and Japanese (6.9%)
counterparts (Kao, 2010). Even though the number of uninsured Korean Americans has declined
due to a series of policy changes by the Patient Protection and Affordable Care Act (ACA),
including Medicaid expansion and the individual mandate rule, Korean Americans still have the
highest uninsurance rates (12.9%) among the Asian Americans (e.g. Chinese: 8.7%, Vietnamese:
10.7%, and Japanese: 4.8%) (Park et al., 2018). Lack of health insurance can negatively impact
healthcare access (Cook et al., 2014), health service use (Danis et al, 2006; Hadley, 2003), and
eventually the overall health outcomes (McWilliams, 2009; Wilper et al., 2009). As such, the lower
health insurance coverage of Korean Americans should be considered as a critical public health
issue. However, the reasons for such disparities in health insurance coverage among this
population are poorly understood.
Studies have cited economic factors as plausible causes for the lower health insurance
coverage (Dubay, Holahan, & Cook, 2007; Schoen, Osborn, Squires, & Doty, 2013; Schoen et
al., 2010); yet economic factors remain insufficient in comprehensively explaining the poor
insurance take-up (Bundorf & Pauly, 2006). This necessitates an attempt to shift our attention
from economic to behavioral factors that influence decision-making to purchase insurance plans

30
(Mathur, Das, & Gupta, 2018). According to the theory of planned behaviors, individuals’
behaviors are strongly determined by intention to engage in the behaviors; and the intention is
influenced by beliefs and attitudes regarding the behaviors (Ajzen, 1991). Applying the theory to
the insurance purchase, if a person holds strong beliefs that purchasing health insurance will
bring desired benefits, this leads to positive attitudes toward insurance purchase; the positive
attitudes result in higher intention and the person is more likely to purchase insurance plans. On
the other hand, if a person holds beliefs that purchasing health insurance is not a reasonable
choice, the negative beliefs shape negative attitudes towards insurance purchase, resulting in
weak intention; and the person is less likely to be enrolled in insurance plans.
Previous literature on health care access of Korean Americans has shown that Korean
Americans have negative perceptions of U.S. health insurance (Choi, 2013; Oh & Jeong, 2017),
which could be largely influenced by socio-cultural factors as with other immigrant populations
(Leduc & Proulx, 2004; Portes et al., 1992). Korean Americans easily use the pre-migration
healthcare experience as a sociocultural referent to evaluate U.S. health insurance and health care
delivery system in regard to affordability, accessibility, or quality of services (Choi, 2013). The
health insurance system in Korea is operated by a single-payer, the National Health Insurance,
which provides universal, convenient, and relatively inexpensive health insurance (Choi, 2013;
Jeong, 2011; Nguyen et al., 2015; Ryu et al., 2001), whereas the U.S. health insurance had been
optional, complicated, and relied heavily on private market through employers’ financial support
(Bilheimer & Colby, 2001). Furthermore, research has revealed that the negative perceptions of
health insurance among Korean immigrants are likely to be influenced by ethnic social networks
where negative opinions and cultural norms regarding U.S. health insurance are frequently
generated and disseminated (Oh & Jeong, 2017). A qualitative study of the influence of ethnic

31
networks on decisions to purchase health insurance among Korean Americans revealed that
Korean Americans often shared negative perceptions of health insurance to other members in
their ethnic networks even though they did not have experience with U.S. health insurance,
which, in turn, discouraged purchasing of health insurance (Oh & Jeong, 2017).
A sizable number of studies has consistently provided evidence that perceptions of health
insurance are associated with decisions to enroll in health insurance (Chemin, 2018; Jehu-
Appiah, Aryeetey, Agyepong, Spaan, & Baltussen, 2012; Mathur et al., 2018; Monheit &
Vistnes, 2008; Nshakira-Rukundo, Mussa, Nshakira, Gerber, & von Braun, 2019). Mathur et al.
(2018) investigated the effects of perceptions of insurance on preference to purchase private
voluntary health insurance. They found a significant difference in perceptions of health insurance
between the insured and uninsured household. Jehu-Appiah et al. (2012) also revealed that the
uninsured had more negative perceptions than the insured about benefits, convenience, and price
of health insurance.
Despite the ACA, a sizable portion of Korean Americans still do not have health
insurance (Park et al., 2018). It is important to understand what factors suppress the increase of
insurance coverage in this population. Based on the theoretical guidance and empirical evidence
of the previous literature, we can hypothesize that perceptions of health insurance among Korean
Americans could affect their enrollment of health insurance. However, no empirical study has
been conducted to examine the possible association between perceptions of health insurance and
health insurance coverage among Korean Americans. Thus, the present study aimed to 1)
understand how Korean Americans perceived U.S. health insurance and to 2) examine whether
the perceptions of health insurance are associated with health insurance coverage among Korean
Americans.

32
Methods
Data
Data were drawn from surveys of non-elderly Korean American adults aged between 26
and 64, who are required to have health plans by the ACA. Using a purposive sampling method,
community-based samples who met the age eligibility were recruited through Korean community
churches in the Greater Los Angeles area. The Greater Los Angeles area has the heaviest
concentrations of Korean Americans in the United States (O’Connor & Batalova, 2019), which
thus provides unique opportunities to collect relevant data about Korean Americans living in
ethnic enclaves. Local churches were selected as a primary place of data collection because of its
central functions to develop Korean American communities (Min, 1992). The survey took place
at multiple locations and events (e.g. churches, small group fellowship meetings) from July to
October in 2018. Participants were asked to complete a self-administered questionnaire either in
Korean or English based on their preference. It took respondents about 30 minutes to complete
the questionnaire. Participants were given $5 gift card for participation after completing the
survey. The project was approved by the Institutional Review Board at the University of
Southern California (UP-18-00375). A total of 584 Korean Americans was participated in the
survey. After removal of those who were not eligible due to age criteria (n = 35), the final sample
consisted of 549 participants.
Measures
The survey instrument consisted of five sections inquiring about respondents’ health
conditions, health service utilization, health insurance, source of health information, and socio-
demographic characteristics. Survey questions were derived from several standardized
questionnaires including SF-8 Health Survey (Lefante, Harmon, Ashby, Barnard, & Webber,

33
2005) for health conditions, Cornell Services Index (Sirey et al., 2005) and Patient Satisfaction
Questionnaire Short Form (PSQ-18) (Thayaparan & Mahdi, 2013) for health service utilization.
Questions related to health insurance were developed based on the questionnaire of the Survey
on Public Satisfaction with Korean National Health Insurance (KNIH) (Lee, Suh, & Song, 2009)
and the qualitative study findings of the present thesis (Chapter 2). For the source of health
information, the survey questions of Pew Research Center used to investigate source of
information on health and health care of Hispanic population were used (Livingston, Minushkin,
& Cohn, 2008). The survey questionnaires are available in Appendix B (English) and Appendix
C (Korean).
Among the five sections of the survey instrument, this study focused the section related
to health insurance. The insurance-related section included items inquiring about 1) insurance
enrollment status, 2) types of health insurance if enrolled, 3) frequency of insurance use for care,
and 4) general opinions and attitudes towards health insurance in regard to cost, benefits,
accessibility to providers, simplicity of policies, access to information, awareness of benefits, use
of benefits, perceived necessity of health insurance for health care, and intention to hold health
insurance even if not mandatory, and 5) perceptions of overall quality of health insurance.
Health Insurance Coverage
Participants were asked their current status of health insurance at the point of data
collection. Respondents were then categorized into two groups: being currently insured (1) and
uninsured (0).
Perceptions with Health Insurance
Respondents were asked to indicate how strongly they agreed or disagreed with twelve
statements describing perceptions of health insurance in the United States in regard to cost,

34
benefits, accessibility to healthcare providers, simplicity of policies, access to information,
awareness of benefits, use of benefits, perceived necessity of health insurance for health care,
and intention to hold health insurance even if not mandatory. Response consisted of five options
from ‘strongly agree’ (score of 5) to ‘strongly disagree’ (score of 1). Mean scores of the twelve
items were used to indicate overall perceptions of health insurance. Higher scores indicate more
positive perceptions of health insurance (range from 1 to 5). Among a total of 549 respondents,
92% (n = 504) of the sample responded to the items regarding perceptions of health insurance,
and 86% (n = 472) completed all the twelve items. For the respondents with missing responses (n
= 32, 6%), mean imputation was applied. The Cronbach alpha of this measure was 0.91.
Covariates
Background information included socio demographic characteristics (age, gender, marital
status, monthly household income, educational attainment, employment), immigration-related
characteristics (citizenship, length of residence in the U.S., English proficiency), and health-
related characteristics (self-rated health status, presence of chronic illnesses). Age (in years),
monthly household income (USD), lengths of residence in the U.S., and self-rated health status
(6 = excellent, 5 = very good, 4 = good, 3 = fair, 2 = poor, 1 = very poor) were included in the
models as continuous variables. Gender (1 = female, 0 = male), marital status (1 = married, 0 =
not married), educational attainment (1 = college or more, 0 = less than college), English
proficiency (1 = speaking English only / very well / well, 0 = not well / not at all), citizenship (1
= U.S. citizen, 0 = non-U.S. citizen), and presence of chronic health conditions (1 = yes, 0 = no)
were dichotomized. The category ‘not married’ included single, widowed, divorced, and others;
‘non-U.S. citizen’ included a permanent resident with a green card, visa holder, and others.
Employment were categorized into three groups: 1) self-employed, 2) employed in other sectors

35
including private, non-profit organization/foundation, and government, and 3) unemployed/out-
of-labor-force. The out-of-labor-force included homemaker, retiree, and student.
Statistical Analyses
First, to explore the perceptions of health insurance among Korean Americans, bivariate
analyses using t-test were conducted to compare perceptions of specific aspects of health
insurance depending on enrollment status. Each response to 12 items regarding the perceived
quality of specific aspects of health insurance were compared between the insured and uninsured.
The perceptions of overall quality of health insurance (mean scores of the 12 items) were also
compared by enrollment history (never enrolled / enrolled before the ACA and currently insured
/ enrolled before the ACA but currently uninsured / enrolled due to ACA / others). For these
bivariate analyses, Bonferroni corrections were applied for potential inflation of type I error.
Multivariate logistic regression models were used to examine if perceptions of overall quality of
health insurance are associated with health insurance coverage. A set of covariates consisting of
demographic (age, gender, marital status, income, employment), immigration-related
(citizenship, length of residence in the United States, English proficiency), and health-related
(self-rated health status, presence of chronic conditions) characteristics were included in the
model. All analyses were performed using SAS 9.4 and STAT 15.1.
Results
Sample Characteristics
Descriptive characteristics of the overall sample are summarized in Table 3.1. The mean
age of the overall sample was 46.3 years (SD = 9.9). Most of the respondents were born in Korea
(96%); more than half (52.1%) were U.S. citizens. The number of years of residence in the U.S.
averaged 18.5 years (SD = 10.2 years), and over a half (50.8%) of the sample were English

36
Table 3.1. Sample Characteristics
n (M) % (SD)
Socio-demographic
Age (in year) (46.3) (9.9)
Female 341 62.1
Married 426 77.6
Monthly income ($) (6,856) (4,837)
College or more 388 70.7
Self-employed 104 18.9
Employed in other sectorsa 344 62.7
Unemployed / out-of-labor-forceb 71 12.9
Immigration-related
Country of birth (Korea) 526 95.8
U.S. citizen 286 52.1
Years in the U.S. (18.5) (10.2)
English proficient 279 50.8
Health-related
Self-rated health (3.8) (0.9)
Chronic conditions 165 30.1
Insurance enrollment
Currently being insured 438 79.8
History of enrollment status
Never had health insurance 32 5.8
Enrolled before the ACA, and currently insured 252 45.9
Enrolled before the ACA, but currently uninsured 24 4.4
Enrolled due to the ACA 138 25.1
Others 71 12.9
Insurance typec
Covered California 97 22.2
Medicaid (Medi-Cal) 68 15.5
Employment-based plans 217 49.5
Private plans 29 6.6
Others 16 3.7
Note.
a. Employees in other sectors than self-employment including private company, non-profit organization /
foundation, and government
b. Out-of-labor-force includes homemakers, retirees, and students
c. Responses from those currently being insured (n = 438)

37
proficient (speaking English only, very well, and well). Almost 80% were currently insured;
about 46% continued to have health insurance acquired before the ACA, and about 25% newly
enrolled in health insurance plans due to the ACA. Among the insured, 50% had employer-
sponsored plans; 22% purchased health insurance through Covered California; 16% were
covered by Medi-Cal. Only about 7% purchased private health insurance regardless of the ACA.
About 4% of the insured reported as ‘others’ (n = 16) for insurance plans, which included
international insurance plans (n = 5), student insurance plans (n = 3), Kaiser Permanente (n = 3),
LA Care (n = 2), Veterans Medical Benefits (n = 1), United Healthcare (n = 1), and Hawaii
Medical Service Association (n = 1).
Perceptions of Health Insurance and Health Insurance Coverage
Table 3.2 presents the results of bivariate analysis comparing perceptions of health
insurance between the insured and uninsured respondents. In general, the insured respondents
showed significantly more positive perceptions of health insurance than the uninsured (t = 6.4, p
< .001). Specifically, the insured respondents showed significantly higher scores of positive
perceptions regarding health insurance than the uninsured with respect to affordability (items 1,
2), coverage of benefits (items 3, 4), accessibility to healthcare providers (items 5, 6), simplicity
of insurance policies (item 7), access to information about health insurance (item 8), awareness
and use of insurance benefits (items 9, 10), needs of insurance for health care (item 11), and
intention to hold health insurance regardless of the individual mandate rule (item 12).
Table 3.3 presents the results of bivariate analyses examining whether the levels of
positive perceptions of overall quality of health insurance differ by enrollment history. Of note,
respondents who had never enrolled in U.S. health insurance (Group 1, n = 20) also responded to

Table 3.2. Comparison of Perceptions of Health Insurance by Status of Enrollment

Items
Insured
(n = 420)
Uninsured
(n = 79) t-value
Meana (SD)a Meana (SD)a
1. Health insurance premium is affordable. 3.04 (0.75) 2.45 (0.78) 5.0***
2. Out-of-pocket cost (deductible, copayment) is affordable. 3.04 (1.23) 2.18 (1.16) 5.7***
3. The coverage of health insurance stretches far enough to cover a range
of medical services or prescription drugs that I need.
3.19 (1.20) 2.20 (1.11)
6.7***
4. Compared to the benefits, the insurance cost is fair and reasonable. 2.59 (1.13) 1.99 (0.99) 4.4***
5. It is easy to access the network hospitals included in my coverage. 2.92 (1.21) 2.41 (1.21) 3.3***
6. It is convenient to choose health care providers that I want. 2.62 (1.11) 2.23 (1.10) 2.8***
7. It is easy to understand the policies of health insurance. 2.47 (1.05) 2.14 (0.96) 2.5***
8. I have easy access to information on health insurance. 2.84 (1.06) 2.47 (1.08) 2.9***
9. I am well aware of the benefits of my health insurance. 2.84 (1.06) 2.51 (1.01) 2.6***
10. I make good use of my health insurance benefits. 2.98 (1.07) 2.39 (1.08) 4.4***
11. I believe that I definitely need health insurance for health care. 4.33 (0.84) 3.90 (1.04) 4.0***
12. Even if it is not mandatory, I will keep having health insurance. 3.85 (1.06) 2.87 (1.16) 7.3***
Total 3.04 (0.75) 2.45 (0.78) 6.4***
Note. * p < .05, ** p < .01, *** p < .001;
a. 5 = strongly agree, 4 = agree, 3 = uncertain, 2 = disagree, 1 = strongly disagree
38

39
these questions in regard to health insurance based on their general perceptions. Those who
enrolled in insurance plans before the ACA and currently insured (Group 2, M = 3.12, SD =
0.76) perceived health insurance more positively compared to other groups including those who
had never enrolled in U.S. health insurance (Group 1, M = 2.52, SD = 0.64), those who had been
insured before the ACA but currently uninsured (Group 3, M = 2.59, SD = 0.84), and those who
newly enrolled in insurance plans due to the ACA (Group 4, M = 2.76, SD = 0.78). No
significant differences were found in the levels of positive perceptions of health insurance
between those who had never had health insurance (Group 1) and those who had been insured
before the ACA but currently uninsured (Group 3).

Table 3.3. Levels of Positive Perceptions of Health Insurance by Enrollment History
Group Enrollment History N Perceptions Fb Group
Difference
Meana SD
1 Never enrolled 20 2.52 0.64 8.01*** 2**
2 Enrolled before ACA, and currently insured 245 3.12 0.76 1**, 3*, 4***
3 Enrolled before ACA, but currently uninsured 24 2.59 0.84 2*
4 Enrolled due to ACA 132 2.76 0.78 2***
5 Others 64 2.96 0.78
Total 485 2.95 0.79
Note. * p < .05, ** p < .01, *** p < .001
a. 5 = strongly agree, 4 = agree, 3 = uncertain, 2 = disagree, 1 = strongly disagree

Table 3.4 presents the logistic regression model of health insurance coverage. In the
unadjusted model, the positive perceptions of health insurance were positively associated with
the odds of having health insurance (OR = 2.87, 95% CI = 2.02 – 4.07). In the adjusted model,
the effect size slightly decreased but remained still significant after controlling for socio-
demographic, immigration-related, and health-related characteristics (OR = 2.80, 95% CI= 1.76
– 4.45). Among the covariates, being employed in other sectors than self-employment (OR =

Table 3.4. Effects of Perceptions of U.S. Health Insurance on Health Insurance Coverage Among Korean Americans

Unadjusted
(n = 499)

Adjusted
(n = 370a)

OR 95% CI OR 95% CI
Perceptions of health insurance 2.87*** [2.02 - 4.07] 2.80*** [1.76 - 4.45]
Socio-demographic
age 1.02*** [0.97 - 1.07]
Female (ref. male) 0.88*** [0.42 - 1.82]
Married (ref. not marriedb) 1.61*** [0.70 - 3.68]
College or more (ref. less than college graduation) 1.60*** [0.76 - 3.37]
Monthly income 1.06*** [0.98 - 1.16]
Employed in other sectorsc (ref. self-employed) 2.33*** [1.00 - 5.42]
Unemployed/out-of-labor-forced (ref. self-employed) 2.66*** [0.73 - 9.67]
Immigration-related
Citizen (ref. non-U.S. citizene) 2.41*** [1.05 - 5.54]
The number of years of residence in the U.S. 0.98*** [0.93 - 1.03]
English proficientf (ref. speaking English not well/not at all) 1.51*** [0.72 - 3.20]
Health-related
Self-reported health 1.42*** [0.96 - 2.09]
Chronic illnesses (ref. no chronic illnesses) 1.23*** [0.57 - 2.62]
Note. * p < .05, ** p < .01, *** p < .001;
a. The number of missing responses by variables: female (n = 1), married (n = 4), college or more (n = 12), monthly income (n = 86), employed in other
sectors (n = 30), unemployed/out-of-labor-force (n = 30), citizen (n = 4), the number of years in the U.S. (n = 18), English proficient (n = 30), chronic
illnesses (n = 1), perceptions of health insurance (n = 45), insurance enrollment status (n = 6);
b. ‘Not married’ includes single, widowed, divorced, and others;
c. ‘Other sectors’ includes private company, non-profit organization/foundation, and government;
d. ‘Out-of-labor-force’ includes homemakers, retirees, and students;
e. ‘non-U.S. citizen’ includes a permanent resident with a green card, visa holder, and others;
f. ‘English proficient’ includes speaking English only / very well / well.

40

41
2.33, 95% CI = 1.00 – 5.42) and citizenship (OR = 2.41, 95% CI= 1.05 – 5.54) were positively
associated with health insurance coverage.
Discussion
Using survey data collected in Korean ethnic communities, this study examined whether
perceptions of health insurance are associated with insurance coverage among Korean
Americans. The results from the multivariate models confirmed that positive perceptions of U.S.
health insurance are associated with being insured, controlling for other influential factors on
health insurance coverage. The findings of the study are in line with previous findings of the
literature that individuals with positive perceptions, attitudes, or preference regarding health
insurance are more likely to enroll in health insurance (Jehu-Appiah et al., 2012; Monheit &
Vistnes, 2008; Nshakira-Rukundo et al., 2019). The findings would corroborate the arguments
that economic factors may not be the only barrier to obtaining coverage of the uninsured
(Bundorf & Pauly, 2006) and non-economic factors including perceptions of health insurance
could be considered as a significant determinant of health insurance coverage (Saver &
Doescher, 2000).
The findings of the study also indicated that the levels of positive perceptions of health
insurance differed by respondents’ history of enrollment. Specifically, those who continued to
have health insurance even before the ACA had significantly higher levels of positive
perceptions of health insurance compared to those who newly purchased health insurance due to
the ACA. This may imply the possibility that part of the previously uninsured respondents might
purchase health insurance due to avoid penalty imposed by the individual mandate rules of the
ACA, despite their negative perceptions of health insurance. The findings also indicated that the
respondents, who had health insurance before the ACA but currently were uninsured, showed

42
low levels of positive perceptions of health insurance, following those who had never enrolled in
health. This may suggest that some of the respondents who had health insurance in the past could
have negative perceptions of health insurance based on their prior experiences, which might
affect their decisions to keep health insurance. These findings are consistent with the previous
literature revealing that perceptions of health insurance have a positive association with renewing
insurance plans (Nshakira-Rukundo et al., 2019).
However, it should be noted that the analytic approach of this study is based on the
assumption that perceptions of health insurance are exogenous from insurance purchase. The
assumption of strict exogeneity of perceptions of health insurance from enrollment status posited
in the analytic framework of the present study may not hold given that the survey was conducted
after respondents purchased health insurance due to the ACA. The responses to the question
about general perceptions about health insurance could reflect either past or current experience
with health insurance. Respondents’ current experience of health insurance may condition
responses about perceptions of health insurance. This could compromise our ability to claim that
our measure of perceptions is exogenous. Given this concern, more conservative approach to the
interpretation of the finding of this study is required in terms of the association between
perceptions of health insurance and insurance coverage rather than claiming a strict, causal
relationship.
The findings of the study, on the other hand, suggest that the impacts of the ACA on
health insurance coverage would be disproportionate depending on subpopulations among
Korean Americans. In this study, household income did not have a significant association with
insurance coverage, which was inconsistent with the findings of previous studies using data
collected prior to the passage of the ACA (Kao, 2010; Nguyen et al., 2015). This may imply

43
favorable effects of the ACA on insurance coverage by reducing financial burden for coverage
by subsidies and Medicaid expansion. Nevertheless, self-employed Korean Americans were
significantly less likely than employees in other sectors including private company, non-profit
organization/foundation, and government to have health insurance. The data of the present study
showed that the average household income level of the self-employed ($ 8,305/month) is higher
than that of employees in private or public sectors ($6,943/month). Given the financial capability
among the self-employed as well as governmental subsidies provided by the ACA, it is possible
that the lower insurance rates among the self-employed Korean Americans would be partly
attributed to non-economic factors beyond affordability (Bundorf & Pauly, 2006). First, it is
plausible that self-employed Korean Americans would have weak preference for coverage
(Monheit & Harvey, 1993) and high tolerance for risk (Barsky, Juster, Kimball, & Shapiro,
1997), which are important factors in health enrollment decisions (Monheit & Vistnes, 2008). In
addition, social contexts where self-employed Korean Americans are situated might hinder them
from purchasing health insurance. Previous literature indicated that knowledge and information
about health insurance among the uninsured can promote insurance enrollment, and personal
networks could play a key role as the primary source of the information (Chemin, 2018;
Nshakira-Rukundo et al., 2019). However, self-employed Korean Americans might hardly have
a chance to obtain relevant information for decisions to purchase health insurance from their
personal networks because most of the network members have negative opinions about health
insurance (Oh & Jeong, 2017). This contextual factor may affect the decision not to purchase
health insurance among the self-employed Korean Americans.
Some limitations of this study should be noted. First, despite the attempt to include
diverse groups of Korean Americans, generalizability of the study findings is quite limited by the

44
non-probability sampling method. This study employed purposive sampling methods and
collected samples though Korean community churches in the Greater Los Angeles area. Even
though majority of Korean Americans have been affiliated with Korean community churches
(Pew Research Center, 2012), the study sample could not represent the whole Korean population
in California as well as in the United States. Second, as aforementioned, due to the possible
endogeneity of the measure of perceptions of health insurance and cross-sectional design, we
cannot strongly claim the causality of the association between perceptions of health insurance
and health insurance coverage among Korean Americans. This limitation should be addressed by
adopting more valid measures of perceptions of health insurance and longitudinal study designs
or conducting in-depth qualitative research to explore the changes in perceptions of health
insurance prior to and after having health insurance and to understand the roles of perceptions in
purchasing health insurance after the implementation of the ACA. Lastly, this study applied
mean imputation for the missing cases of perceptions of health insurance, which can cause
underestimation of variance of the variable and consequently result in biased results. For more
unbiased parameter estimates and standard errors, alternative approaches including Full
Information Maximum Likelihood (FIML) should be applied.
Despite these limitations, the present study is the first study to examine the association
between perceptions of health insurance and insurance coverage among Korean Americans.
Given the high uninsured rates among Korean Americans and the recent changes in health
policies to eliminate the individual mandate rule, more attention is needed for the factors
influencing Korean Americans’ health coverage. The present study found relatively negative
perceptions of health insurance among the uninsured and even in the newly insured, which
suggests the necessity of further research for more in-depth understanding of the negative

45
perceptions and the importance of health education targeted at these population. The educational
intervention should not be limited to informing insurance plans but include more generic
information including the purpose of health insurance, benefits, financial security, and impacts
on improving access to timely services and continuity of care. The results of this study are
expected to extend our understanding of the determinants of health insurance coverage among
Korean Americans and provides salient implications to health researchers, educators, health
policy makers and health insurance providers given the current, unstable climate around
healthcare policies in the United States.

46
CHAPTER 4: MANUSCRIPT 3
“Effects of Social Networks on Health Insurance Coverage Among Korean Americans”

Abstract
Objectives. This study examines the effects of social networks on health insurance coverage
among Korean Americans.
Methods: Using purposive sampling, 549 non-elderly Korean Americans (aged 26 – 64) were
recruited through Korean community churches in the Greater Los Angeles area from July to
October in 2018. Participants completed a self-administrative survey about health insurance. In
addition, ego-centric network data were collected by asking respondents (egos) to name up to
five people (alters) with whom the respondents talked about health issues. Several characteristics
about the alters, including types of information that respondents obtained from each alter (e.g.
health insurance, health service providers, etc.) and levels of satisfaction with the information
obtained from the alters. The sizes of health discussion networks were measured by the number
of people elicited by respondents. After that, the health discussion networks were narrowed
down by limiting the topic of conversation to health insurance. The adjusted insurance discussion
networks were re-adjusted by levels of satisfaction with the insurance-related information
obtained from the network members. Multivariate logistic regressions were conducted to
examine whether the sizes of social networks where participants obtained insurance-related
information were associated with health insurance coverage, controlling for individual attributes
including demographic, socio-economic, immigration-related, and health-related characteristics.
Perceptions of health insurance were also included in the analytic models as a covariate due to a

47
potential confounding effect on the association between sizes of health insurance discussion
networks and health insurance coverage.
Results. The average size of health discussion networks was 2.76 (SD = 1.6). The health
discussion networks were positively associated with health insurance coverage (OR = 1.31, p
< .01). The effect sizes were larger when the topic of health discussion was limited to health
insurance (OR = 1.41, p < .05) and when respondents perceived the insurance-related
information was satisfying (OR = 1.89, p < .05). Perceptions of health insurance played a role as
a suppressor on the associations between social networks and health coverage. Respondents
perceived satisfied when they received information from male or colleagues in workplaces.
Perceptions of health insurance played a role as a suppressor on the association between social
networks and insurance coverage.
Conclusions. Social networks, particularly targeted for information regarding health insurance,
increased the likelihood of being insured. These findings will contribute to development of
effective health education interventions using social networks to promote health insurance
coverage among Korean Americans.

Keywords: Social networks; health insurance coverage; quality of information; perceptions of
health insurance; Korean Americans

48
Effects of Social Networks on Health Insurance Coverage Among Korean Americans

Introduction
Disparities in health insurance coverage among ethnic groups have been well
documented (Buchmueller, Levinson, Levy, & Wolfe, 2016; Fiscella & Sanders, 2016). Korean
Americans are one of the most vulnerable ethnic minority groups in regard to health insurance
coverage (Kao, 2010; Nguyen et al., 2015). As the Patient Protection and Affordable Care Act
improved health insurance coverage, the number of uninsured Korean Americans has drastically
declined; however, the insured rates of Korean Americans still remain the lowest among Asian
Americans in the U.S. (Park et al., 2018). Studies have attempted to explain the lower insurance
coverage of Korean Americans, mostly focusing on economic and/or acculturation-related
factors (Cook et al., 2014; Huang & Carrasquillo, 2008; Kao, 2010; Nguyen et al., 2015; Ryu et
al., 2001; Shin et al., 2005); yet, a large variance of the coverage among Korean Americans were
unexplained by those economic and acculturation-related factors (Kao, 2010; Nguyen et al.,
2015).
One of the limitations of the previous research is that these studies have focused solely on
individual-level attributes including income, education, employment, English proficiency, and
citizenship, consequently, failing to capture the potential influences of contextual factors
including social networks. The choice of individuals’ health behaviors is influenced by social
contexts where the individuals are situated (Abel, 2008; Berkman, Glass, Brissette, & Seeman,
2000). Likewise, the decision to purchase health insurance among Korean Americans could be
influenced by immediate social contexts including ethnic networks in their communities (Choi,
2013; Oh & Jeong, 2017).

49
With respect to health insurance coverage, studies have revealed associations between
social networks and health insurance enrollment (Chemin, 2018; Ko, Kim, Yoon, & Kim, 2018;
Nshakira-Rukundo et al., 2019; Oraro, Ngube, Atohmbom, Srivastava, & Wyss, 2018). For
instance, Chemin (2018) introduced a randomized experimental design to compare the effects of
financial assistance (subsidies) on in-patient insurance take-up and the effects of provision of the
information through informal groups (close friends) without subsidies. The results showed that
the financial assistance increased take-up rates to 45%. However, once the subsidies were
discontinued, the retention rate was close to zero. On the other hand, informal group meetings
increased the take-up rates to 12%; 7% still retained the insurance a year after the intervention.
He suggested that social learning or peer pressure could explain the results. Qualitative
debriefing of the study showed that insurance-related information to the informal group meetings
triggered discussions about the insurance led by early adopters of the in-patient insurance. The
early adopters shared positive experiences about the insurance in the group meetings, which
resulted in increased knowledge and trust of the insurance among the participants. In contrast,
distrust and/or a lack of information about the insurance, resulting in poor understanding of the
product, were reported as major causes that people chose not to take up the insurance (Chemin,
2018). Nshakira-Rukundo (2019) also found that access to information is one of the influential
factors affecting enrollment and renewing of community-based health insurance.
As noted by Chemin (2018), normative and behavioral guidance occurs when individuals
compare their beliefs, attitudes, and behaviors with similar others in their reference groups
(Thoits, 2011). A qualitative study indicated that social networks of Korean immigrants can
enhance maladaptive health behaviors such as decisions not to purchase health insurance (Oh &
Jeong, 2017). The authors revealed that Korean immigrants usually obtain health information

50
from other members in person networks. However, most of the health information shared in the
networks was about strategies of coping with acute health needs without health insurance. For
those without health insurance, information regarding health insurance was rarely shared among
social network members. Rather, they often discussed with personal network members how to
use health care services without health insurance when they had urgent needs for health care (Oh
& Jeong, 2017). Similarly, Luque et al. (2018) revealed that social networks could play a role as
a coping mechanism to use health care services for acute health needs among uninsured Latina
immigrants.
Individuals’ choice sets could be restricted as a result of lack of effective information
(Thiede, 2005). For example, Pih et al. (2012) pointed out that sufficient social capital among
Chinese immigrants in Southern California did not properly work in providing relevant health
care information from mainstream society due to a lack of cultural capital. This finding
highlights the importance to account for the quality of information that individuals can obtain
from their social networks. Relevant information regarding health insurance purchase, which
includes information about insurance benefits and details in policies, seemed to be rarely
available in social network members among Korean immigrants (Oh & Jeong, 2017).
Furthermore, they were easily exposed to negative beliefs and norms about U.S. health insurance
from their social ties, which also discouraged the uninsured Korean immigrants from purchasing
health insurance (Oh & Jeong, 2017).
The knowledge about social network effects on health insurance coverage from previous
studies is quite limited because most of the studies used proxy measures of social networks (i.e.
levels of social support, reciprocity, etc.) and focused primarily on abstract features of social
networks such as social capital (i.e. levels of trust and reciprocity). Consequently, previous

51
literature failed to reveal which structural conditions of social networks can be operationalized.
Furthermore, for the insurance coverage among Korean Americans, only qualitative research has
been conducted. To our best knowledge, no quantitative research has been conducted to
investigate the effects of social networks on health insurance coverage among Korean Americans
in the United States. Similar to the findings of previous studies revealing social network effects
on health insurance coverage, it is plausible that social networks could exert a positive influence
on health insurance coverage among Korean Americans through social learning or normative
pressure (Chemin, 2018), given many Korean Americans have purchased health insurance after
the implementation of the ACA (Park, et al., 2018). On the other hand, it is also plausible that
social networks exert a negative influence on health insurance coverage through the same
mechanisms (social learning and normative pressure), as observed in Korean immigrants (Oh &
Jeong, 2017). However, there is little evidence by which we can confirm whether social
networks facilitate or inhibit insurance enrollment among this at-risk minority population.
The present study aimed to examine whether health discussion networks of Korean
Americans exert a positive influence or a negative influence on their health insurance coverage.
This study particularly focused on the size of social networks where individuals obtained
insurance-related information. With respect to the effects of social networks on health insurance
coverage, it would be important to distinguish general health discussion networks from insurance
discussion networks specified by the topic of conversation. Given the fact that Koreans rarely
obtain information about health insurance from their personal health discussion networks (Oh &
Jeong, 2017), both network size and network content were taken into account in this study.
Furthermore, it would also be imperative to take account of the levels of satisfaction with health
information obtained from the insurance discussion networks because the quality of information

52
from the personal networks could be influential on the individuals’ behaviors regrading health
insurance enrollment (Chemin, 2018; Pih et al., 2012). Thus, this study investigated how
insurance discussion networks of Korean Americans are associated with their health insurance
coverage, accounting for the levels of satisfaction with insurance-related information obtained
from the networks.
Methods
Data Collection
Participants were recruited using a purposive sampling method from July to October in
2018 through Korean community churches in Greater Los Angeles area where Korean
Americans are heavily concentrated (O’Connor & Batalova, 2019). Participants were eligible if
they were non-elderly Korean Americans aged between 26 and 64 who are required to have
health plans by the ACA individual mandate. The Korean community church was chosen as a
primary source of recruitment because of its central role in developing ethnic networks among
Korean Americans. Korean churches in the United States have functioned as a relevant social
institution where Korean Americans could receive formal/informal services and information on
diverse issues including health insurance and health care (Kim, Kreps, & Shin, 2015; Min,
1992); more than 70% of Korean Americans have been affiliated with Christian churches (Pew
Research Center, 2012). The surveys were conducted at multiple locations and events including
regular church services and small group fellowship meetings. A self-administered questionnaire
was developed both in Korean and English so that participants could choose a survey language
based on their preference. It took respondents about 30 minutes to complete the 8-page
questionnaire. After completing the survey, $5 gift cards were given to the participants. The
study was approved by a university Institutional Review Board. A total of 584 Korean

53
Americans from 60 churches participated in the survey. After removal of those who were not
eligible due to age criteria (n = 35), the final sample consisted of 549 participants.
Social Network Data
Characteristics of social networks where respondents obtain health information were
collected through a name generator and a name interpreter (Campbell & Lee, 1991). Participants
(egos) were asked for the initials of up to 5 people (alters) with whom they talk about their health
concerns. Attributes of each alter – the person nominated by a respondent – perceived by the
respondents were then asked including alters’ gender (female / male), ethnicity (Korean / not
Korean), relationships with respondents (family / friend / colleague at work / church member /
neighbor / other), position in church (pastor / staff / cell leader / cell member / fellow / others) –
only if the relationships of alters with respondents were identified as church members, frequency
of contact (daily / once a week / once a month / once a year), topic of conversation (health
insurance / health services / others), and levels of satisfaction with the health information
obtained from each alter (very satisfied / satisfied / neutral / not satisfied / never satisfied). For
specific attributes of alters including types of relationship with respondents and topics of
conversation, respondents were allowed to select multiple options. In terms of alters’ position in
church, cell leader and cell member were included in the response options given that Korean
church members often obtain informative and instrumental support from cell groups, which play
critical roles in the ministry of Korean churches (Kwon, Ebaugh, & Hagan, 1997).
Measures
Health Insurance Coverage
Participants were asked whether they had health insurance at the point of data collection
(yes / no). Respondents were then categorized into the insured (1) and the uninsured (0).

54
Health Discussion Networks
The sizes of health discussion networks were measured by the number of alters elicited,
with whom respondents usually talked about their health concerns. The sizes of the health
discussion networks were then narrowed down by limiting both topics of conversation and levels
of satisfaction with health information obtained from alters. First, in regard to the topic of
conversation, among all alters elicited, only those with whom respondents talked specifically
about health insurance were counted as insurance discussion networks. For example, if a
respondent nominated five alters with whom the respondent talked about general health concerns
(i.e. health care providers, clinics, health problems, health behaviors, etc.), and only three of
them were reported to discuss health insurance with the respondent, the size of insurance
discussion networks was counted as three. In addition, the insurance discussion networks were
re-adjusted by levels of satisfaction with the insurance-related information obtained from the
alters. In the name interpreter, respondents were asked to rate the levels of satisfaction with
health information obtained from each alter using a five-point Likert scale (5 = very satisfied, 4 =
satisfied, 3 = neutral, 2 = not satisfied, 1 = never satisfied). This measure was then dichotomized
into satisfying information (1 = very satisfied / satisfied) and not satisfying information (0 =
neutral / not satisfied / never satisfied) to identify alters who provided respondents with
satisfying information regarding health insurance. For example, if a respondent had three alters
providing insurance-related information, and among the three alters, only two alters were
perceived as to provide satisfying information (“very satisfied / satisfied” in the original scale of
satisfaction levels with health information), the adjusted size of insurance discussion networks
with satisfying information was counted as two. Lastly, a sensitivity analysis was added in order
to examine the effects of social networks which provide dissatisfying information about health

55
insurance. Similar procedures used in the process to identify the insurance discussion networks
providing satisfying information were applied. First, an additional dummy variable was created
by recategorizing the levels of satisfaction with health information obtained from health
discussion networks into dissatisfying information (1 = never satisfied / not satisfied) and not
dissatisfying information (0 = neutral / satisfied / very satisfied). After that, the same
aforementioned procedure for the insurance discussion networks providing satisfying
information was applied to adjust the health discussion network sizes where respondents
obtained insurance-related information which was perceived as dissatisfying.
Covariates
Several socio-demographic, immigration-related, and health-related characteristics were
included in the models as covariates. Specifically, the covariates included age (in years), gender
(1 = female, 0 = male), marital status (1 = married, 0 = not married), household income (USD),
educational attainment (1 = college or more, 0 = less than college), employment (1 = full-time
employed / part-time employed, 0 = unemployed / out-of-labor-force including homemakers,
retirees, and students / others), English proficiency (1 = speaking English only / very well / well,
0 = not well / not at all), citizenship (1 = U.S. citizen, 0 = non-U.S. citizen including permanent
residents with a green card, visa holders, and others), length of residence in the U.S. (in years),
self-rated health status (6 = excellent, 5 = very good, 4 = good, 3 = fair, 2 = poor, 1 = very poor),
and presence of chronic health conditions (1 = yes, 0 = no). In addition, overall perceptions of
U.S. health insurance (5 = very satisfied, 4 = satisfied, 3 = neutral, 2 = not satisfied, 1 = not
satisfied at all) were also included as a covariate in the model considering a possibility that both
the size of the insurance discussion networks and health insurance coverage might be influenced
by personal beliefs or attitudes regarding health insurance (Oh & Jeong, 2017).

56
Statistical Analyses
Background information of the sample was described including socio-demographic,
immigration-related, and health-related characteristics as well as insurance-related characteristics
(e.g. enrollment status, type of health insurance, and use of health insurance for health services).
Descriptive statistics of health discussion networks were reviewed. From the 549 respondents, a
total of 1,499 dyadic data (ego-alter ties) were generated by reshaping the wide format data,
where each respondent is considered as one observation (n = 549), to a long-form data, where
each alter is considered as one observation (n = 1,499). Attributes of the alters were reviewed
including gender, ethnicity, whether working in health-related fields, relationship with
respondents, position/roles in church, frequency of contact, topic of conversation, and
respondents’ perceived levels of satisfaction with information that alters provided the
respondents. The sizes of overall health discussion networks as well as sub-groups of health
discussion networks specified by the characteristics of ego-alter ties including alters’
demographic attributes, type of relationship, frequency of contact, topic of conversation, and
levels of satisfaction with health information obtained from alters were summarized. Bivariate
analyses between health insurance coverage and health discussion network sizes (unadjusted /
adjusted by topic of health information and levels of satisfaction with the health information)
were conducted. Then, separate logistic regression models were used to examine the effects of
social networks on health insurance coverage. Specifically, in model 1, the unadjusted health
discussion networks regardless of topic of the conversation with alters and levels of satisfaction
with information obtained from alters were used. In model 2, the health discussion networks in
model were modified to insurance discussion networks where respondents obtained information
about health insurance were used. In model 3 and model 4, the insurance discussion networks in

57
model 2 were re-adjusted by levels of satisfaction with the insurance-related information
obtained from alters. Across all the models, a set of covariates including socio-demographic
(age, gender, marital status, income, employment), immigration-related (citizenship, length of
residence in the United States, English proficiency), and health-related (self-rated health status,
presence of chronic conditions) characteristics were included. In addition, considering potential
associations of how positively or negatively respondents perceive health insurance with both
insurance discussion network sizes and health insurance coverage (Oh & Jeong, 2017), a variable
indicating respondents’ perceptions of overall quality of U.S. health insurance was also included
in the analytic models as a covariate. Additional analyses were conducted to identify which
specific attributes of alters were associated with the levels of satisfaction with information about
health insurance. Multilevel modeling was employed to adjust for potential dependency among
the alters from a respondent (Vacca, Stacciarini, & Tranmer, 2019). Using the dyadic data (n =
1,499), linear mixed effects analyses were performed to examine the relationships between
alters’ attributes and levels of satisfaction with insurance-related information obtained from the
alters. The attributes of alters included alters’ gender, ethnicity, relationship with respondents,
position in church, and frequency of contact. The mixed effects models estimated fixed effects
coefficients for alter-level variables (alters’ attributes) and respondent-level variables (covariates
in the main analyses) while adjusting for random intercepts between respondents. All analyses
were performed using SAS 9.4 and STATA 15.1.
Results
Sample Characteristics
Table 4.1 shows general characteristics of the sample. Socio-demographic, immigration-
related, and health-related characteristics as well as insurance-related characteristics were

58
described. The age of the overall sample averaged 46.3 years (SD = 9.9); over 62% were female;
and about 78% were married. The majority of the sample were college graduates or more (71%),
employed (76%), and born in Korea (96%). About half of the respondents were U.S. citizen
(52%) and English proficient (51%). The average years of living in the U.S. was 18.5 years (SD
= 10.2 years). With respect to health conditions, the average score of the self-rated health was 3.8
(SD = 0.9); and about 30% of the respondents had chronic diseases. Eighty percent of the sample
were currently insured. Among the insured respondents (n = 438), almost 50% were covered by
employment-based plans, 22% by plans purchased through Covered California, 16% by Medi-
Cal, and 7% by private plans and 4 % by others (n = 16), which included international insurance
plans (n = 5), student insurance plans (n = 3), Kaiser Permanente (n = 3), LA Care (n = 2),
Veterans Medical Benefits (n = 1), United Healthcare (n = 1), and Hawaii Medical Service
Association (n = 1). About 57% of the insured respondents reported that they always use health
insurance for health care services. Almost half of the insured (43%) did not always use health
insurance for health care even though they have health insurance.
Table 4.2 presents descriptive statistics of personal networks in which respondents obtain
health information. Means and standard deviations of the sizes of personal networks and the
frequency and percentage of the social ties (dyadic data) were shown, sorted by alters’ attributes.
About 64% of alters were female, and in terms of gender-concordance, 66% of alters had the
same gender with respondents. The majority of alters (91%) were Koreans. With respect to the
type of relationship between respondents and alters, family members accounted for about 36%,
followed by friends (29%), church members (15.9%), and colleagues (13%). In terms of
frequency of contact, about 45% of alters contacted respondents on weekly basis; 32% of alters
contacted them on daily basis. In regard to topic of conversation, about 66% of alters talked

59
Table 4.1. Sample Characteristics

Total
(n = 549)
n (M) % (SD)
Socio-demographic
Age (in year) (46.3) (9.9)
Female 341 62.1
Married 426 77.6
Monthly income (USD) (6,856) (4,837)
College or more 388 70.7
Employed 431 78.5
Immigration-related
Country of birth (Korea) 526 95.8
U.S. citizen 286 52.1
Lengths of residence in the U.S. (in year) (18.5) (10.2)
English proficient 279 50.8
Health-related
Self-rated health (3.8) (0.9)
Chronic conditions 165 30.1
Insurance enrollment
Currently being insured 438 79.8
History of enrollment status
Never had health insurance 32 5.8
Enrolled before the ACA, and currently insured 252 45.9
Enrolled before the ACA, but currently uninsured 24 4.4
Enrolled due to the ACA 138 25.1
Others 71 12.9
Insurance typea
Covered California 97 22.2
Medicaid (Medi-Cal) 68 15.5
Employment-based plans 217 49.5
Private plans 29 6.6
Others 16 3.7
Insurance use for health servicesa
Always use 248 56.6
Most of the time
108 24.7
Sometimes 23 5.3
Occasionally
34 7.8
Never use 20 4.6
Note.
a. Responses from those currently being insured (n = 438)

60
about health care services including clinics or healthcare providers. Only 30% of alters talked
with respondents about health insurance and about 25% of alters talked about other topics related
to health (e.g. health problems, health behaviors). In terms of level of satisfaction with the health
information that respondents obtained from alters, almost half of the alters (49%) were perceived
to provide information that was satisfying (34.8%) or very satisfying (13.7%).
Table 4.2. Characteristics of Health Discussion Networks by Alters’ Attributes
Note.
a. Concordance of gender between respondents and alters (1 = matched, 0 = not matched);
b. Multiple (duplicated) selection was allowed.

Individuals
(n = 549)
Dyadic Data
(n = 1,499)
M SD n %
Demographic attributes of alters
Female 1.85 1.33 963 64.2
Male 1.03 0.96 536 35.8
Gender-concordancea 1.87 1.33 981 65.6
Korean 2.59 1.49 1,355 90.8
Type of relationship
Family member 1.03 1.11 534 35.7
Friend 0.84 1.08 435 29.1
Colleague 0.38 0.78 196 13.1
Church member 0.46 0.82 238 15.9
Neighbor 0.12 0.47 63 4.2
Others 0.06 0.35 31 2.1
Frequency of contact
Daily 0.92 1.09 476 32.1
Weekly 1.28 1.37 664 44.7
Monthly 0.55 0.87 283 19.1
Yearly 0.12 0.42 62 4.2
Topic of conversationb
Health insurance 0.84 1.22 439 29.6
Healthcare services 1.90 1.54 986 66.4
Other topics 0.71 1.20 367 24.7
Satisfaction with information obtained from alters
Very satisfied 0.39 0.90 204 13.7
Satisfied 1.00 1.20 518 34.8
Neutral 1.34 1.43 695 46.7
Not satisfied 0.10 0.42 54 3.6
Never satisfied 0.03 0.24 16 1.1

61
Table 4.3 presents health insurance coverage depending on the sizes of unadjusted health
discussion networks (model 1) and adjusted health discussion networks by limiting the topic of
conversation to health insurance (model 2) and accounting for the levels of satisfaction with
information obtained from alters (model 3 & model 4). The overall health discussion network
sizes averaged 2.76 (SD = 1.6) (model 1). This means, respondents, on average, discussed health
issues with about two to three people in their personal networks. The sizes of health discussion
networks adjusted by topic of conversation (health insurance) averaged 0.84 (SD = 1.22) (model
2). When the adjusted network sizes by topic of conversation is re-adjusted by levels of
satisfaction with the information obtained from alters, the average sizes of health discussion
networks decreased to 0.44 (SD = 0.91) (model 3) and 0.04 (SD = 0.26) (model 4), respectively.
The rates of being insured were found to gradually increase as the sizes of health discussion
networks increased except for model 4. The associations between network sizes and health
insurance coverage were statistically significant for model 1 and model 2, and marginally
significant for model 3 (ORmodel1 = 1.21, p < .01; ORmodel2 = 1.27, p < .05; ORmodel3 = 1.38, p
= .05; ORmodel4 = 0.8, p = .58).
Table 4.4 presents the effects of health discussion networks on health insurance coverage.
In model 1, controlling for other covariates, the sizes of health discussion networks increased the
odds of having health insurance by 1.31 times (95% CI = 1.07 – 1.59). In model 2 where the
sizes of the health discussion networks were adjusted by limiting the topic of conversation to
health insurance (insurance discussion networks), one unit increase in the size of the insurance
discussion networks significantly increased the odds of having health insurance by 1.41 times
(95% CI = 1.02 – 1.94). In model 3 and model 4, the sizes of the insurance discussion networks
were re-adjusted by levels of satisfaction with information obtained from alters. Results showed

62
Table 4.3. Descriptive Statistics on Sizes of Health Discussion Networks and Health Insurance Coverage
Model 1a Model 2b Model 3c Model 4d
Network
Sizes
n
(M)
%
(SD)
Insured
%
n
(M)
%
(SD)
Insured
%
n
(M)
%
(SD)
Insured
%
n
(M)
%
(SD)
Insured
%
Overall (2.76) (1.60) (0.84) (1.22) (0.44) (0.91) (0.04) (0.26)
- None 26 4.7 0.73* 284 51.7 0.77 382 69.6 0.79 503 97.1 0.81
- One 119 21.9 0.73* 124 22.6 0.87 75 13.7 0.87 10 1.9 0.88
- Two 127 23.1 0.85* 49 8.9 0.82 31 5.6 0.84 4 0.8 0.5
- Three 100 18.2 0.75* 32 5.8 0.84 17 3.1 0.88 1 0.2 1
- Four 38 7.1 0.84* 15 2.7 0.93 4 0.7 1.00 - - -
- Five 133 25.0 0.88* 11 2.0 0.91 4 0.7 1.00 - - -
Note.
a. Unadjusted health discussion networks
b. Health discussion networks adjusted by topic of conversation (limited to insurance-related information)
c. Health discussion networks adjusted by satisfaction with the insurance-related information
d. Health discussion networks adjusted by dissatisfaction with the insurance-related information

63
Table 4.4. Effects of Health Discussion Networks on Health Insurance Coverage

Model 1a
(n = 379e)

Model 2b
(n = 363)

Model 3c
(n = 363)

Model 4d
(n = 363)
OR 95% CI OR 95% CI OR 95% CI OR 95% CI
Sizes of health discussion networks 1.31*** [1.07 - 1.59] 1.41*** [1.02 - 1.94] 1.88*** [1.07 - 3.32] 0.74*** [0.32 - 1.69]
Perceptions of health insurance 2.02*** [1.42 - 2.86] 2.15*** [1.48 - 3.11] 2.14*** [1.47 - 3.11] 2.03*** [1.41 - 2.91]
Socio-demographic factors
age 1.01*** [0.97 - 1.05] 1.02*** [0.98 - 1.06] 1.02*** [0.98 - 1.06] 1.02*** [0.97 - 1.06]
Female (ref. male) 1.01*** [0.52 - 1.93] 0.92*** [0.47 - 1.81] 0.91*** [0.46 - 1.80] 0.90*** [0.46 - 1.77]
Married (ref. not marriedf) 2.04*** [0.95 - 4.39] 1.84*** [0.83 - 4.04] 1.82*** [0.83 - 4.02] 1.90*** [0.87 - 4.17]
College or more (rel. less than college) 1.28*** [0.64 - 2.58] 1.52*** [0.74 - 3.14] 1.52*** [0.74 - 3.13] 1.51*** [0.74 - 3.08]
Monthly income (USD) 1.06*** [0.98 - 1.15] 1.06*** [0.98 - 1.15] 1.06*** [0.97 - 1.15] 1.06*** [0.98 - 1.16]
Employed (ref. not employedg) 0.79*** [0.33 - 1.92] 0.74*** [0.29 - 1.88] 0.75*** [0.30 - 1.90] 0.71*** [0.28 - 1.77]
Immigration-related factors
Citizen (ref. non-U.S. citizenh) 2.73*** [1.27 - 5.86] 2.61*** [1.19 - 5.73] 2.60*** [1.19 - 5.67] 2.79*** [1.28 - 6.08]
The number of years in the U.S. 0.97*** [0.93 - 1.02] 0.97*** [0.93 - 1.02] 0.97*** [0.93 - 1.02] 0.97*** [0.92 - 1.01]
English proficient (ref. limited English
Proficienti)
2.06*** [1.01 - 4.19] 1.58*** [0.75 - 3.33] 1.66*** [0.79 - 3.49] 1.87*** [0.90 - 3.87]
Health-related factors
Self-reported health 1.30*** [0.92 - 1.83] 1.29*** [0.90 - 1.86] 1.27*** [0.89 - 1.82] 1.30*** [0.90 - 1.86]
Chronic illnesses (ref. no health conditions) 1.61*** [0.79 - 3.26] 1.65*** [0.79 - 3.42] 1.57*** [0.76 - 3.27] 1.62*** [0.78 - 3.34]
Note. *p<.05, **p<.01, ***p<.001;
a. Model 1: Unadjusted health discussion networks
b. Model 2: Health discussion networks adjusted by topic of conversation (limited to insurance-related information)
c. Model 3: Health discussion networks adjusted by satisfaction with the insurance-related information
d. Model 4: Health discussion networks adjusted by dissatisfaction with the insurance-related information
e. The number of missing responses by variables: female (n = 1), married (n = 4), college or more (n = 12), monthly income (n = 86), employed in other
sectors (n = 30), unemployed/out-of-labor-force (n = 30), citizen (n = 4), the number of years in the U.S. (n = 18), English proficient (n = 30), chronic
illnesses(n = 6), perceptions of health insurance (n = 39);
f. ‘Not married’ includes single, widowed, divorced, and others;
g. ‘Not employed includes unemployed, out-of-labor-force (i.e. homemaker, retiree, and student), and others;
h. ‘Non-U.S. citizen’ includes a permanent resident with a green card, visa holder, and others;
i. ‘Limited English proficient’ includes speaking English not well or not at all.

64
that the sizes of insurance discussion networks where respondents obtained insurance-related
information, which was perceived satisfying by the respondents (model 3), significantly
increased the odds of having health insurance by 1.88 times (95% CI = 1.07 – 3.32). In other
words, if a respondent has one more person who provides the respondent with satisfying
information about health insurance, the respondent is almost two times more likely to have
health insurance. On the other hand, the sizes of insurance discussion networks where
respondents received insurance-related information, which was perceived not satisfying (model
4), were not associated with health insurance coverage.
Table 4.5 presents the results of sensitivity analyses where perceptions of health
insurance were excluded from the models. Results showed that the sizes of the overall health
discussion networks regardless of the topic of conversation were positively associated with
having health insurance (OR = 1.28, 95% CI = 1.07 – 1.53) (model 1). However, when the sizes
of health discussion networks were adjusted by the topic of conversation (model 2) and levels of
satisfaction with insurance-related information obtained from alters (model 3), the significant
associations between health discussion networks and health insurance coverage in the main
analyses were no longer statistically significant.
Finally, mixed effects models were performed to identify which attributes of alters were
associated with levels of satisfaction with the information obtained from alters. Results are
shown in Appendix D. Controlling for respondent-level characteristics, alters as colleagues in
workplaces were positively associated with levels of satisfaction with health information from
alters (b = 0.38, p < .01). On the other hand, female alters were negatively associated with levels
of satisfaction with the health information (b = -0.25, p < .01).

Table 4.5. Effects of Health Discussion Networks on Health Insurance Coverage (Without Perceptions of Health Insurance)

Model 1a
(n = 402)

Model 2b
(n = 386)

Model 3c
(n = 386)

Model 4d
(n = 386)
OR 95% CI OR 95% CI OR 95% CI OR 95% CI
Sizes of health discussion networks 1.28*** [1.07 - 1.53] 1.28*** [0.96 - 1.69] 1.56*** [0.96 - 2.55] 0.74*** [0.32 - 1.70]
Socio-demographic factors
age 1.00*** [0.97 - 1.04] 1.01*** [0.97 - 1.05] 1.01*** [0.97 - 1.05] 1.01*** [0.97 - 1.05]
Female (ref. male) 1.02*** [0.57 - 1.85] 0.98*** [0.54 - 1.79] 0.98*** [0.53 - 1.79] 1.01*** [0.55 - 1.84]
Married (ref. not marriedf) 2.12*** [1.07 - 4.20] 1.93*** [0.96 - 3.88] 1.94*** [0.97 - 3.90] 2.08*** [1.04 - 4.16]
College or more (rel. less than college) 1.49*** [0.80 - 2.80] 1.75*** [0.92 - 3.34] 1.81*** [0.95 - 3.42] 1.79*** [0.94 - 3.38]
Monthly income (USD) 1.04*** [0.96 - 1.12] 1.04*** [0.96 - 1.12] 1.03*** [0.96 - 1.12] 1.04*** [0.97 - 1.12]
Employed (ref. not employedg) 0.85*** [0.39 - 1.86] 0.81*** [0.36 - 1.82] 0.82*** [0.37 - 1.85] 0.79*** [0.35 - 1.77]
Immigration-related factors
Citizen (ref. non-U.S. citizenh) 3.12*** [1.56 - 6.22] 3.13*** [1.54 - 6.34] 3.14*** [1.56 - 6.33] 3.23*** [1.60 - 6.52]
The number of years in the U.S. 0.98*** [0.94 - 1.03] 0.98*** [0.94 - 1.02] 0.98*** [0.94 - 1.03] 0.98*** [0.94 - 1.02]
English proficient (ref. limited English
Proficienti)
2.10*** [1.10 - 4.02] 1.75*** [0.90 - 3.43] 1.76*** [0.90 - 3.45] 1.91*** [0.98 - 3.70]
Health-related factors
Self-reported health 1.44*** [1.06 - 1.97] 1.43*** [1.03 - 1.98] 1.40*** [1.01 - 1.94] 1.42*** [1.03 - 1.97]
Chronic illnesses (ref. no health conditions) 1.77*** [0.92 - 3.42] 1.79*** [0.91 - 3.51] 1.75*** [0.89 - 3.43] 1.75*** [0.89 - 3.43]
Note. *p<.05, **p<.01, ***p<.001;
a. Model 1: Unadjusted size of personal networks where respondents obtained health-related information;
b. Model 2: Adjusted size of personal networks where respondents obtained insurance-related information;
c. Model 3: Adjusted size of personal networks where respondents obtained satisfying insurance-related information;
d. Model 4: Adjusted size of personal networks where respondents obtained unsatisfying insurance-related information;
e. The number of missing responses by variables: female (n = 1), married (n = 4), college or more (n = 12), monthly income (n = 86), employed in other
sectors (n = 30), unemployed/out-of-labor-force (n = 30), citizen (n = 4), the number of years in the U.S. (n = 18), English proficient (n = 30), chronic
illnesses (n = 6), perceptions of health insurance (n = 39);
f. ‘Not married’ includes single, widowed, divorced, and others;
g. ‘Not employed includes unemployed, out-of-labor-force (i.e. homemaker, retiree, and student), and others;
h. ‘Non-U.S. citizen’ includes a permanent resident with a green card, visa holder, and others;
i. ‘Limited English proficient’ includes speaking English not well or not at all.
65

66
Discussion
Using social network data collected from community-based samples, this study
investigated the effects of social networks on health insurance coverage among Korean
Americans. Particularly, this study focused on the sizes of social networks as one of the key
features of social network structure, considering the social networks as a relevant source of
health information. The results indicated that the sizes of personal health discussion networks
where Korean Americans obtain health information, particularly regarding health insurance, are
positively associated with being insured. The findings are in line with previous studies revealing
that individuals’ decision to purchase health insurance could be influenced by social networks
(Chemin, 2018; Nshakira-Rukundo et al., 2019). As shown in the previous literature, the findings
of the study suggest a possibility that social networks may exert positive effects on health
insurance coverage through social learning or transmission of information through social
networks (Chemin, 2018; Fenenga et al., 2015; Thiede, 2005).
The results of this study also suggest the importance of quality of information obtained
from health discussion networks in the effects of social networks on health insurance coverage.
The effect sizes of health discussion networks on insurance coverage increased when the health
information obtained from network members was specified to insurance-related information. The
effects of insurance discussion networks further increased when respondents perceived that the
information obtained from their personal health discussion networks was satisfying. These
results are in line with previous studies indicating that the amount of informational resources
within social networks affect individuals’ access to health care (Choi, 2013; Pih et al., 2012;
Thiede, 2005). On the other hand, when respondents perceived that the insurance-related
information obtained from personal health discussion networks were dissatisfying, there was no

67
significant association between the sizes of insurance discussion networks providing
dissatisfying information and health insurance coverage. However, this result seems to be merely
due to lack of statistical power, given more than 97% of the respondents reported that they had
no insurance discussion networks which provided dissatisfying information.
The descriptive statistics of the study regarding health discussion networks may imply
lack of relevant information to purchase health insurance among Korean Americans. The sizes of
health discussion networks where respondents seek for information about health insurance were
smaller than those of the networks regarding healthcare-related information. The health
discussion networks obtaining insurance-related information (M = 0.84, SD = 1.22) were much
smaller than those obtaining healthcare-related information (M = 1.9, SD = 1.54). The results are
consistent with previous findings that most of the health information that Korean Americans seek
for from their personal networks are restricted to health care services rather than health insurance
(Kim et al., 2015; Oh & Jeong, 2017).
The major type of relationship with network members as a source of information was
family members, friends, and church members, which is also in line with previous literature
(Kim et al., 2015). Of note, the levels of satisfaction with information received from network
members were significantly influenced by whether the members are colleagues in workplace or
not. Respondents reported greater levels of satisfaction when they talked about health insurance
with their colleagues even though they are not the major source of information regarding health
insurance. These findings imply that the source of health information may differ depending on
the area of health concerns, suggesting the importance of providing relevant information tailored
to individuals’ specific situations and health needs. In addition, the levels of satisfaction with
information received from network members were also associated with gender. Respondents

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reported lower levels of satisfaction when they talked about health insurance with female alters.
Given a possibility that, for some reasons, the alters who provided respondents with relevant
information about health insurance in workplaces are likely to be male, a potential correlation
between gender and coworkers were reviewed. Bivariate and multivariate analyses on these
variables, however, showed that gender and coworkers were not correlated with each other and
independently associated with the levels of satisfaction with health information. The other
possible explanation is gender stereotype that perceived levels of credibility about information
may differ depending on whether the sources of the information is male or female (Armstrong,
2009). The gender stereotype could be moderated by cultural values (Cuddy et al., 2015).
However, this claim could not be examined by the current data. Further studies need to be
conducted to figure out the underlying reasons why male alters were perceived to provide more
satisfying information regarding health insurance among Korean Americans.
One of the interesting findings of the study was the role of perceptions of health
insurance in the association between social networks and health insurance coverage. Based on
the findings of previous literature that negative perceptions of health insurance might affect both
the likelihood of having conversation about health insurance and intention to purchase health
insurance (Oh & Jeong, 2017), this study included a variable indicating perceptions of overall
quality of health insurance as a covariate in the analytic models. As sensitivity analyses, the
models without the variable of perceptions of health insurance were also analyzed to compare the
results with the findings of main analyses. The results showed that the significant association
between health discussion networks and health insurance coverage disappeared when perceptions
of health insurance were not controlled. Interestingly, without perceptions of health insurance in
the model, the effects of social networks on health insurance still remained significant only when

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the networks were not adjusted by topic of conversation. Once the unadjusted health discussion
networks were constrained as the insurance discussion networks where respondents talked about
health insurance, the associations between social networks and health insurance coverage were
no longer significant. Additional analyses were conducted to understand the associations among
perceptions of health insurance, sizes of health discussion networks, and health insurance
coverage. The results showed that perceptions of health insurance were negatively associated
with the sizes of insurance discussion networks (b = -.57, p < .05). In contrast, there was no
significant association between perceptions of health insurance and sizes of unadjusted health
discussion networks. In regard to health insurance coverage, the perceptions of health insurance
seem to weaken the association between insurance discussion networks where individuals obtain
insurance-related information and health insurance purchase (MacKinnon, Krull, & Lockwood,
2000). It is plausible that the uninsured, who are likely to have negative perceptions of health
insurance (Jehu-Appiah et al., 2012; Mathur et al., 2018), could try to seek information about
health insurance in order to enroll in health insurance. On the other hand, the insured may have
less incentive to seek for information about health insurance because they already have health
insurance. Consequently, it is plausible that the uninsured with negative perceptions with health
insurance are more likely than the insured to talk about health insurance. It is also possible that
the uninsured are more likely than the insured to talk about health insurance to complain about
negative aspects of health insurance as a way of justification for their uninsured status. In any
cases, perceptions of health insurance should be considered as a key player to explain the effects
of social networks on health insurance coverage. Without accounting for the effects of
perceptions of health insurance both on insurance discussion networks and insurance coverage,

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we likely fail to reveal the existing association between social networks and health insurance
coverage.
Some limitations to this study should be noted. First, the findings of the present study
could not be generalized to overall Korean American population in the United States. The study
used a non-probability sampling method, which restricts our ability to generalize the results.
Participants were recruited through with Korean community churches, which may condition the
characteristics of the sample in regard to network composition and major sources of information.
Future studies should consider including Korean Americans who are not affiliated with Korean
community church as a study population. Second, causality among the variables may not hold
strictly due to the cross-sectional research design. Despite the efforts to reduce the likelihood of
selection bias by accounting for the perceived satisfaction with health information acquired from
social networks and overall perceptions of health insurance in the analytic models, the research
design could not exclude potential endogeneity among the independent and dependent variables,
limiting our ability to draw causal inferences. Nevertheless, the findings of the study are relevant
in that the study revealed the roles of ethnic social networks of Korean Americans in the
diffusion of health information regarding health insurance. Lastly, the use of a single item
assessing perceptions of health insurance or quality of information obtained from social networks
is also a limitation. For example, the measure of quality of information obtained from social
networks did not provide enough information about which aspects of the information made
respondents satisfied. People might feel satisfied when the information they gain from network
members is informative, answering to their questions. On the contrary, it is also possible that
people would be satisfied when the information they gain from network members confirms their
prior beliefs about health insurance. Future studies should include more comprehensive, valid

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instruments measuring perceptions of health insurance and the quality of with health
information.
Despite these limitations, the present study expands our understanding of the roles of
social networks in the diffusion of information regarding health insurance (Choi, 2013; Thiede,
2005). The information distributed through social networks can influence peoples’ decision to
enroll in health insurance (Chemin, 2018; Fenenga et al., 2015; Nshakira-Rukundo et al., 2019).
Further studies are needed to investigate the barriers and facilitators regarding insurance
enrollment among Korean Americans. Particularly, necessary is more information about the
influential social networks where newly insured people obtained relevant health information in
the process of enrollment, and how the information influence their decision to purchase health
insurance. These findings will contribute to development of effective health education
interventions using social networks to promote health insurance coverage.

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CHAPTER 5: DISCUSSION
Equitable access to health care is a critical foundation of health and well-being. Korean
Americans, however, have consistently experienced lower rates of health insurance coverage
compared to other Asian ethnic subgroups (Kao, 2010; Nguyen et al., 2015; Park et al., 2018),
highlighting the importance of understanding influential factors for the disparities in health care
access among this vulnerable population. Previous studies have attempted to explain the health
care disparities by focusing on socioeconomic, immigration-related, and health-related factors;
however, a large variance in the coverage among Korean Americans still remains unexplained
(Chang, Chan, & Han, 2014; Cook et al., 2014; Ryu, Young, & Kwak, 2002).
Recent health literature recognizes the importance of understanding how contextual
factors (e.g. culture, social networks, and system-level barriers) contribute to individuals’ health
care (Derose, Gresenz, & Ringel, 2011; Gresenz, Rogowski, & Escarce, 2007; Nguyen et al.,
2015). For instance, Nguyen et al. (2015) suggest that Korean Americans who experienced and
were accustomed to the Korean health insurance system, which is universal, simple, and
relatively inexpensive (Jeong, 2011; Ryu et al., 2001), might have more negative attitudes
towards the U.S. health insurance system, resulting in the decision not to purchase health
insurance (Nguyen et al., 2015), which is called “origin effects,” meaning that the characteristics
of countries of origin can affect post-migratory behaviors of immigrants in the host countries
(Van Tubergen, Maas, & Flap, 2004). In addition, social networks can play an important role in
health care access by influencing the transmission of health information (Gresenz et al., 2007).
However, evidence from qualitative research suggested that social networks of Korean
Americans might negatively affect health insurance coverage by reinforcing negative beliefs
about U.S. health insurance among Korean Americans (Oh & Jeong, 2017). Social networks may

73
exert both a positive and a negative influence on health care access in this subpopulation.
However, little is known what kind of influence social networks exert on insurance coverage
among Korean Americans. To address the gaps in the literature, this dissertation used a mixed-
methods approach to comprehensively understand access to health care among Korean
Americans, focusing on health insurance coverage.
Previous chapters included three manuscripts that focus on understanding how socio-
cultural factors influence health insurance coverage among Korean Americans. The first study
(qualitative analysis) revealed that Korean Americans’ pre-migration experience regarding health
insurance and health care services could influence their perceptions of U.S. health insurance,
playing a role as a reference. Korean Americans have cultural values and norms regarding health
insurance, which were derived from their past experience. The second study (quantitative
analysis) revealed that negative perceptions of health insurance among Korean Americans would
play a role as an impediment to insurance purchase. The third study (social network analysis)
revealed that ethnic social networks among Korean Americans could increase the likelihood of
being insured by delivering relevant information regarding the decision to purchase health
insurance.
The findings of this study have relevant implications to health researchers, health
insurance providers, health educators, and health policy makers. First, further studies on diverse
factors influencing insurance enrollment should be continued. As shown in the findings of the
present study, health insurance coverage can be determined by various socio-cultural factors in
addition to economic factors. Due to the Tax Cuts and Jobs Act, insurance enrollment is no
longer mandatory at the federal level. Except for a few states, a majority of the states in the U.S.
do not impose penalty on individuals who are uninsured. It necessitates more in-depth research

74
to understand the changes in insurance coverage and to further increase, at least to retain,
insurance coverage. Furthermore, given the increasing diversity of the U.S. situation where the
population in the U.S. are getting diverse, being constituted of more immigrant populations (Pew
Research Center, 2015), we need to put continuing effort to identify socio-cultural determinants
of health insurance among different ethnic groups, considering different social contexts where
the ethnic groups are situated. This effort should not be limited to insurance coverage. Research
is required to investigate whether increase in health coverage actually lead to increase in use of
health care services when needed. Ethnic minorities including Korean Americans may encounter
various socio-cultural barriers to health care services. In order for each ethnic group to have
equitable access to health care, continuous efforts for research are necessary.
Second, it is necessary to improve insurance plans to reflect diverse cultural health needs.
The findings of the present study highlight the importance of understanding the effects of non-
economic factors on health coverage. Health insurance reform should not be limited to increasing
coverage by financial incentives. More effort should be accompanied to develop culturally
tailored insurance plans, which reflect diverse characteristics and unique health needs of
different ethnic groups. For doing this, it is important to understand perceptions of and
satisfaction with health insurance among the insured, particularly newly insured people after the
ACA. As shown in the previous studies, positive perceptions of health insurance of early
adopters increase the likelihood of the uninsured purchasing health insurance (Chemin, 2018).
Thus, it is critical to understand how the insured perceive their health insurance by evaluating
satisfaction with quality of the insurance, so that more diverse health needs could be met.
Third, along with the improvement of coverage plans, it is critical to provide adequate
health education to raise understanding of health insurance. The findings of this study point to a

75
strategy that encompasses both cultural resources including knowledge and information and
social networks. Due to language barriers, immigrant populations including Korean Americans
lack understanding of health insurance policies including benefits of insurance, which can lead to
lower levels of satisfaction with health insurance. In addition, it is imperative to provide
culturally tailored health education to consider cultural values or beliefs on health insurance. In
terms of the means of delivering of health education, utilizing informal networks could be
considered. For Korean Americans, health information is primarily obtained though informal
networks including friends, family members, or church members (Kim et al., 2015; Oh & Jeong,
2017). Thus, it could be an effective way to employ existing channels to deliver health education
interventions. It would be also important to identify which channels play a key role in diffusion
of information for other ethnic minority groups in order to deliver health education through
culturally appropriate modes. Furthermore, a lack of cultural resources impedes the functions of
social capital in terms of diffusion of information (Pih et al., 2012). Based on the previous
findings on effective ways to deliver information through social networks (Chemin, 2018), it is
needed to develop how to disseminate relevant information for health insurance purchase into the
existing networks among ethnic minority groups.
The dissertation is the first attempt to empirically study using both qualitative and
quantitative approaches the effects of socio-cultural determinants of health insurance among
Korean Americans. The mixed-methods approach of the present study helps us better understand
the multi-faceted influences of the socio-contextual factors on health care access among Korean
Americans. Furthermore, the present study analyzed social network data elicited from a hard-to-
reach population with language barriers, which has never been conducted before. Beyond Korean
Americans, the findings of this study have important implications for immigrants in general. This

76
study supports the necessity of continuous efforts to investigate the influences of socio-cultural
determinants on individuals’ health-related behaviors, especially among ethnic minorities
including immigrants, at different layers of contexts – e.g. interpersonal relationships,
communities, and health care systems. Immigrants, who might have pre-migration experiences
from home countries which have different health care systems from the U.S., could have
culturally unique beliefs, norms, or attitudes towards the U.S. health care system. These cultural
traits could be shared and reinforced within ethnic social networks, which could exert collective
influences on individuals’ health behaviors. In this sense, the study provides a critical foundation
to develop culturally competent interventions not only for Korean Americans but also for other
immigrant population, who might have encountered socio-cultural barriers to access to health
care, to facilitate the process of adjustment to the U.S. health care system.

77
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91

APPENDICES

92
Appendix A. Semi-structured Interview Guide (Study 1)

Health Insurance of Korean Immigrants Working in Small Business
Semi-structured Interview Guide

Interviewee ID: Interview Date:

Before we begin, I want to collect some background information about you.

Background Information

A. Demographic
1. What is your age, please?
2. Are you male or female?
3. Are you now married, living with a partner in a marriage-like relationship, widowed, divorced,
separated, or never married?

B. Employment
1. What kind of job do you do?
2. How many hours per week do you usually work at all jobs or businesses?
3. What is the best estimate of all your earnings last month before taxes and other deductions from
all jobs and businesses, including hourly wages, salaries, tips and commissions?
C. Chronic illnesses
1. In general, how is your health status: excellent, very good, good, fair, or poor?
2. Do you have any chronic illnesses?
i. (For each chronic illness), when did you first find out having the chronic illness?
ii. (For each chronic illness), during the past 12 months, how often have you had severe
symptoms related to your chronic illness?
a. Not at all
b. Less than every month
c. Every month
d. Every week
e. Every day
3. During the past 12 months, have you had to visit a hospital emergency room because of your
chronic illnesses?
i. Yes ii. No
4. If yes, did you visit a hospital emergency room because you were unable to see your doctor?
ii. Yes ii. No
5. During the past 12 months, were you admitted to the hospital overnight or longer for your chronic
illness?
iii. Yes ii. No
6. Are you now taking a daily medication to control your chronic illnesses that were prescribed or
given to you by a doctor?

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Interview Questions

A. Health Insurance and Health Care in South Korea

I would like to listen to your experiences of health insurance and overall health care when you were
living in South Korea.
1. Did you have employment-based health insurance or non-employment-based one?
[Probe: In general, did you often go to see a doctor? In a year, how many times did you usually
do an outpatient or inpatient visit?]
2. What do you generally think about health insurance and health care service in South Korea?
[Probe: What are positive / negative aspects of health insurance and health care in South Korea?]
3. If you have a scale of “1” (very bad) to “10” (very good), how much were you satisfied with (1)
health insurance and (2) health care services in South Korea respectively?

B. Health Insurance and Health Care in the US

Now, let’s talk about health insurance and health care in the US.
1. Do you have health insurance now?
[Probe:
• (If yes) Is it covered by your spouses’ health insurance or your own health insurance?
• (If yes) In a year, how many times do you usually do an outpatient or inpatient visit?
• (If no) Have you ever had health insurance before in the US?
o (If yes) What kind of health insurance you had? Was it employment-based insurance,
a private health insurance, or public health insurance (e.g. Medi-Cal)?
• (If no) When you had no health insurance, how did you use health care?}
2. What do you generally think about health insurance and health care service in the US?
[Probe:
• What are positive / negative aspects of health insurance and health care in the US?
• When you did not have health insurance, how did you address your health issues?
• What do you think are the major differences between South Korea and the US in terms of
health insurance and health care services?
• How much do you think is the reasonable payment for individual health insurance in the US?]
3. If you have a scale of “1” (very bad) to “10” (very good), how much are you satisfied with (1)
health insurance and (2) health care services in the US respectively?

C. Barriers / Facilitators of Health Insurance Purchase in the US

We are going to talk about some barriers and facilitators of health insurance purchase and the use of
health care services.
1. What kind of reasons do you think primarily affect you not to buy health insurance?
[Probe: What are the Top three barriers of health insurance purchase?]
2. When did you feel the need to buy health insurance? What did make you decide to purchase
health insurance?
[Probe: What are the Top three facilitators of health insurance purchase?]
3. According to the research, Korean immigrants had very low rates of health insurance coverage.
Research has shown that this is due to the fact that many Korean immigrants are working in small

94
businesses, which rarely provide health insurance for their workers. However, when we compare
Korean immigrants to other Asian immigrants working in small businesses, Korean immigrants
are still less likely to have health insurance. Do you think there are any special reasons for that?

D. Influences of Social Networks

Next questions are about the people around you, with whom you discuss health issues.
1. With whom do you usually talk about your health issues including health insurance and health
care services?
[Probe:
• Are they all Korean immigrants or are there some other racial/ethnic groups among your
friends?
• From whom do you usually obtain information about health insurance and health care
services?]
2. How do you think were you influenced by these people to purchase health insurance or to remain
uninsured?
3. Among you friends or acquaintances, how much or what percentage do you think have health
insurance?
[Probe: Then, how much by percentage, in your opinion, do you think overall Korean immigrants
in the US have a health insurance in general?]

E. Influences of ACA Implementation

We are almost at the end of the interview. Now I am going to ask you some questions about ACA.
1. Have there been any changes in your life or in Korean communities after the ACA
implementation of the Affordable Care Act (Obamacare)?
2. Did this law actually affect you to purchase health insurance?
3. Did you purchase this insurance through Covered California?
4. Did you receive any kind of subsidies to purchase health insurance?
5. Can you tell me about your thoughts and opinions about the ACA individual mandate?
[Probe: Have you talked about ACA with other people? What was generally said about ACA?]
6. (If having health insurance) Have you used health care with your new health insurance? Can you
tell me what was your experience using the health insurance?
7. What do you think do we need to help Korean immigrants purchase health insurance and use it to
receive adequate health care?
[Probe: What should be changed in health care delivery for Korean immigrants feel higher
satisfaction in using health care services?]

F. Wrap up

1. Is there any additional information regarding health insurance or health care services that I should
know?
2. Do you have any questions for me?

These are all of the questions that I have for you today. I really appreciate you taking the time to
assist us with this survey.

95

STOP TIME:

Interview Comments:
1. Respondent’s level of interest and involvements in answering questions.
Very Low Low Moderate High Very High
1 2 3 4 5

2. Please estimate the respondent’s understanding of the interview
Limited
Understanding
Partial
Understanding
Average
Understanding
Majority
Understanding
Complete
Understanding
1 2 3 4 5

3. Describe any discrepancies, gaps, or other problems with the interview.

4. Describe any circumstances that occurred while the interview was in progress that may have
affected the quality of the interview (i.e., interruptions).

96
Appendix B. Survey Questionnaire (English)

97

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99

100

101

102

7 of 9

D3. Below are questions about people around you. Please provide the information of up to 5 people with whom you talk
about your health concerns. You do not have to report five persons and their names. For your memory, nicknames
or initials are fine. You can check multiple categories if necessary. When you check “Other” please specify it.

Name 1 2 3 4 5
Gender
1 £ Female
2 £ Male
1 £ Female
2 £ Male
1 £ Female
2 £ Male
1 £ Female
2 £ Male
1 £ Female
2 £ Male
Is this person
Korean?
1 £ Yes
2 £ No
1 £ Yes
2 £ No
1 £ Yes
2 £ No
1 £ Yes
2 £ No
1 £ Yes
2 £ No
Working in
health-related
fields?
1 £ Yes
2 £ No
1 £ Yes
2 £ No
1 £ Yes
2 £ No
1 £ Yes
2 £ No
1 £ Yes
2 £ No

How do you
know this
person?
1 £ Family
2 £ Friend
3 £ Work
4 £ Church
5 £ Neighbor
6 £ Other:
1 £ Family
2 £ Friend
3 £ Work
4 £ Church
5 £ Neighbor
6 £ Other:
1 £ Family
2 £ Friend
3 £ Work
4 £ Church
5 £ Neighbor
6 £ Other:
1 £ Family
2 £ Friend
3 £ Work
4 £ Church
5 £ Neighbor
6 £ Other:
1 £ Family
2 £ Friend
3 £ Work
4 £ Church
5 £ Neighbor
6 £ Other:
[If checked
“
$
£ Church”
above]
What is the
position of this
person in the
church?
1 £ Pastor
2 £ Staff
3 £ Cell leader
4 £ Cell member
5 £ Fellows
6 £ Others:

1 £ Pastor
2 £ Staff
3 £ Cell leader
4 £ Cell member
5 £ Fellows
6 £ Others:

1 £ Pastor
2 £ Staff
3 £ Cell leader
4 £ Cell member
5 £ Fellows
6 £ Others:

1 £ Pastor
2 £ Staff
3 £ Cell leader
4 £ Cell member
5 £ Fellows
6 £ Others:

1 £ Pastor
2 £ Staff
3 £ Cell leader
4 £ Cell member
5 £ Fellows
6 £ Others:

How often do
you usually
talk with this
person? At
least…
1 £ Daily
2 £ Once a week
3 £ Once a month
4 £ Once a year
1 £ Daily
2 £ Once a week
3 £ Once a month
4 £ Once a year
1 £ Daily
2 £ Once a week
3 £ Once a month
4 £ Once a year
1 £ Daily
2 £ Once a week
3 £ Once a month
4 £ Once a year
1 £ Daily
2 £ Once a week
3 £ Once a month
4 £ Once a year
Specifically for
health issues,
what do you
usually discuss
with this
person?
1 £ Health
insurance
2 £ Health services
(doctor, clinics…)
3 £ Others:

1 £ Health
insurance
2 £ Health services
(doctor, clinics…)
3 £ Others:

1 £ Health
insurance
2 £ Health services
(doctor, clinics…)
3 £ Others:

1 £ Health
insurance
2 £ Health services
(doctor, clinics…)
3 £ Others:

1 £ Health
insurance
2 £ Health services
(doctor, clinics…)
3 £ Others:

How much are
you usually
satisfied with
the information
from this
person?
1 £ Very satisfied
2 £ Satisfied
3 £ Neutral
4 £ Not satisfied
5 £ Never satisfied
1 £ Very satisfied
2 £ Satisfied
3 £ Neutral
4 £ Not satisfied
5 £ Never satisfied
1 £ Very satisfied
2 £ Satisfied
3 £ Neutral
4 £ Not satisfied
5 £ Never satisfied
1 £ Very satisfied
2 £ Satisfied
3 £ Neutral
4 £ Not satisfied
5 £ Never satisfied
1 £ Very satisfied
2 £ Satisfied
3 £ Neutral
4 £ Not satisfied
5 £ Never satisfied

P

103

104
Appendix C. Survey Questionnaire (Korean)

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7 of 9
D3.
1 2 3 4 5
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P

111

112

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Appendix D. Random-intercept Models of Respondents’ Satisfaction with Health Information by Alters’ Characteristics
Model 1 Model 2
𝛽 SE p-value 𝛽 SE p-value
Alter’s characteristics
Female -0.25*** 0.09 0.006
Coworker 0.37*** 0.14 0.008
Ego’s characteristics
Satisfaction with health insurance -0.17*** 0.07 0.016 -0.16*** 0.07 0.018
Age -0.02*** 0.01 0.073 -0.02*** 0.01 0.081
Female (ref. male) 0.06*** 0.14 0.662 0.00*** 0.14 0.985
Married (ref. not marrieda) 0.36*** 0.18 0.047 0.35*** 0.18 0.053
College or more (rel. less than college) 0.12*** 0.17 0.467 0.10*** 0.17 0.565
Monthly income (USD) 0.00*** 0.02 0.820 0.00*** 0.02 0.760
Employed (ref. not employedb) -0.07*** 0.19 0.713 -0.12*** 0.19 0.525
Citizen (ref. non-U.S. citizenc) 0.24*** 0.16 0.149 0.25*** 0.16 0.125
The number of years in the U.S. 0.00*** 0.01 0.619 -0.01*** 0.01 0.534
English proficient (ref. limited English proficientd) 0.48*** 0.16 0.004 0.49*** 0.16 0.003
Self-reported health 0.03*** 0.08 0.737 0.03*** 0.08 0.720
Chronic illnesses (ref. no health conditions) -0.03*** 0.15 0.842 -0.04*** 0.15 0.798
Note. *p < .05, **p < .01, ***p < .001;
a. ‘Not married’ includes single, widowed, divorced, and others;
b. ‘Not employed includes unemployed, out-of-labor-force (i.e. homemaker, retiree, and student), and others;
c. ‘Non-U.S. citizen’ includes a permanent resident with a green card, visa holder, and others;
d. ‘Limited English proficient’ includes speaking English not well or not at all.

Abstract (if available)

Abstract Objective. To understand the socio-cultural influences on health insurance coverage among non-elderly Korean Americans in California (26 – 64 years), focusing on perceptions of health insurance and social networks, three studies were conducted. Their aims were as follows: 1) to explore how Korean Americans perceive healthcare systems in the U.S. and Korea and how the perceptions affect their intention to purchase health insurance plans

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Asset Metadata

Creator Jeong, Chung Hyeon (author)

Core Title Socio-cultural determinants of healthcare access among Korean Americans

School Suzanne Dworak-Peck School of Social Work

Degree Doctor of Philosophy

Degree Program Social Work

Publication Date 06/22/2020

Defense Date 04/09/2020

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag health insurance,Korean Americans,OAI-PMH Harvest,perceptions of health insurance,pre-migration experience,social networks,socio-cultural determinants

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Lee, Jungeun Olivia (committee chair), Palinkas, Lawrence (committee chair), Valente, Thomas (committee member)

Creator Email chunghyj@gmail.com,chunghyj@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c89-321441

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Rights Jeong, Chung Hyeon

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Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

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