Despite the promise of universal health care in Korea, this study found that a substantial proportion of Koreans had unmet health care needs; this was particularly apparent among people of a lower socioeconomic status (SES). The results also show that individual factors affecting unmet needs vary by gender and by the reasons for the unmet needs. To the author’s knowledge, this study is the first attempt to classify the reasons for unmet health care needs in Korea based on the pervasive classification (i.e., availability-, acceptability, and accessibility-related unmet need) and provides a more complete picture of the problem.
Economic status, commonly represented by income levels, has been thought to be a major risk factor for reporting unmet health care needs, and increasing number of studies suggest policy actions for minimizing economic barriers affecting access to necessary care [18,19,20,21,22]. In this study, the results indicate that income is associated with unmet health care needs. In particular, lower income is associated with higher overall unmet needs in women but not men, and lower income is associated with higher accessibility-related unmet needs in both men and women. These findings are in direct opposition to Kim et al’s recent study on unmet needs [7]. In the previous study, there was insufficient evidence to suggest income impacted unmet health care needs. Part of these differences may be attributed to Kim et al’s decision to pool men and women together as well as their failure to stratify the analyses by the type of unmet health care need.
It is understandable that women and men may experience unmet needs differently. Women, in general, earn lower incomes and have lower-paying positions at work than men, and consequently have more difficulties arranging and attending appointments, accessing necessary services, and communicating their health issues to health professionals [23]. For women who stay at home, familial responsibilities may interfere, preventing them from accessing and utilizing needed health care services [23]. An increased probability of experiencing unmet needs by women in lower-income households suggests more attention be given to developing a gender-sensitive health policy to meet the needs of women with lower incomes [24].
Reasons for unmet health care needs are complex and multi-dimensional, but most existing studies consider an individual’s experience of unmet health care needs as a barrier to accessing health care services [8, 9]. Aggregated self-reported assessments of unmet needs can be a good starting point, but are likely to be considered inadequate for the purpose of developing an effective policy that will truly minimize unmet needs [9]. From this perspective, the results from the three main categories for unmet health care needs point to different policy implications. In relation to accessibility, which encompasses cost and transit related barriers, household income and educational levels were key determinants of unmet need, wherein men and women of the lowest income and educational attainment reported the highest odds of unmet needs. This finding implies that individuals of lower socioeconomic status have more barriers to accessing necessary care compared to their counterparts. Despite successful implementation of Korea’s universal health care system, economic barriers to receiving health services remain [25]. In fact, existing studies of Korean populations suggest that income and educational levels are associated with having a higher probability of experiencing unmet needs along with gender, age, health status, and occupation [5, 26, 27]. This observed relationship between lower SES and experiencing unmet needs is not unique to Korea. Other countries with universal health care systems also report income-related differences in unmet health care needs [12, 28].
To reduce accessibility-related barriers, expanding the current National Health Insurance (NHI) coverage could be a viable option. Previous studies demonstrated that the continuous reforms over the past decades that expanded benefit coverage of the NHI has led to an overall improvement in access to care and service utilization, although higher OOP spending still exists as a possible financial barrier [29,30,31,32,33]. For example, a recent study using the NHI claims data found that, after expanding the NHI benefit coverage of cancer-related services, health services utilization for outpatient and inpatient care increased more in the low-income groups than in the high-income groups [29]. This suggests the relationship between the NHI benefit coverage and access to care provides policy implications that accessibility-related unmet health care needs in lower SES groups could be improved by diminishing financial barriers.
The older age groups were less likely to experience availability-related unmet need compared to the youngest age group in both women and men. Although younger adults are expected to have less health problems compared to older adults, the younger age groups consistently reported more availability-related unmet need across different countries [34, 35]. This may imply that younger people have a higher expectation about health care services, so they are more likely express their dissatisfaction when services are not available [36,37,38,39]. In addition, it is also plausible that younger people tend to be more pro-active about seeking health care services when required, so they may encounter more unavailability of the services they need [40]. Also, marital status was an important factor associated with availability-related unmet health care needs in women. Women who live alone are more likely to express difficulties in finding available health care resources compared to men. In current literature, social support and social capital are closely related to health care utilization and unmet health care needs [23, 41]. One possible explanations is that women living alone have limited social supports, resulting in limited information on where and how to access the services they need [35]. It is also plausible that a larger number of single women contact the health care system in order to seek health care services, which may increase more chances of encountering service unavailability.
Previous studies have suggested that acceptability-related unmet health care needs generally stem from personal preference or circumstance [11, 12]. Due to this quandary, the results are difficult to interpret and policy implications to address this category of unmet need are not clear [11]. However, it is worthwhile to note that acceptability-related unmet needs may be associated with future experiences of, and responses to health care, one of fundamental dimensions of the system effectiveness [42]. Therefore, further research to understand acceptability-related problems needs to be prioritized. In addition, understanding how regional differences affect experiences of unmet need is important considering there is an increasing concern regarding regional inequalities in health and health care. For instance, the results from this study indicate that both women and men living in Busan, Dageu, Ulsan, and Gyeonsang province have higher odds of reporting an overall unmet health care need. Although multiple factors determine an individual’s experience of unmet health care needs, the higher concentration of health care facilities in the Metro-Seoul regions may be driving these regional differences [16, 43]. Regional inequalities in health outcomes and health care utilization have become an increasing concern in Korea and further scrutiny is considered to fully understand how regional differences affect unmet needs and future policy development [44].
Limitations
Some limitations of this study have been identified. The KNHANES is a cross-sectional survey, and the outcome–unmet needs – corresponds to the unmet needs reported in the year prior to the survey. On the other hand, the predictor variables may correspond to the date the data was collected; it is not clear if these predictor variables were stable over the one-year period. While educational attainment tends to be stable across time, other characteristics like self-reported health or household income may not be. In a similar vein, there may be errors related to recalling outcomes in the past 12 months or bias arising from telescoping. These would manifest in misclassification of either predictors or outcomes. Previous studies using self-reported survey data addressed a potential underestimation of the number of experiences of unmet needs [8].
Using a secondary data source, this study was limited by the data that was collected. It can be acknowledged that a wide range of factors that were not included could also impact unmet need, such as provider characteristics. This study also did not have information on the types of health care services that were not received: it is unclear whether unmet needs arose from primary care services, hospital services, or both. It may be necessary to examine unmet health care need with a specific service rather than general experience of unmet health care need as a micro-level investigation focusing on specific health care services is suggested [9, 11, 12]. Instead of adopting a micro-level approach, this study adapted a classification of unmet needs from previous studies [11, 12], and attempted to understand the effect of various SES factors on different types of unmet health care needs. It should also be mentioned that there are two different ways to measure unmet health care needs. Based on clinical assessment, individuals who do not receive appropriate care can be determined as having unmet needs, as well as individuals who self-report their experiences of failing to receive appropriate care when needed. This study used the latter of the two approaches and may overlook the clinical factors associated with unmet health care needs at the individual level. However, previous studies suggest that self-reported experiences of unmet needs can be an appropriate measure when analyzing national population-based surveys [8]. Despite these limitations, the results provide notable information on the experiences of unmet health care need at the population level using a large, representative population-based survey, building on previous research.
