Understanding reasons for unmet health care needs in Korea: what are health policy implications?

Ensuring access to necessary care, regardless of the ability to pay, is one of the major determinants of population health [1]. In the past 30 years, Korea has rapidly structured the National Health Insurance (NHI) system, and has achieved universal coverage for all Korean residents [2]. Despite the current universal health care system, out-of-pocket (OOP) spending for health care purposes is higher relative to other Organisation for Economic Cooperative Development (OECD) countries [3]. It has been estimated that annual household OOP spending accounts for approximately 37% of total household health care spending, and the average rate of OOP spending is expected to continuously increase [4]. The increasing financial burden of OOP expenses may cause an uneven distribution of access to necessary services across socioeconomic groups, adversely affecting access and the utilization of health care services by individuals of lower socioeconomic status (SES) [5, 6]. A recent study on unmet health care needs in Korean adults found that adults with the lowest educational attainment reported the greatest difficulty receiving the health care services they needed [7]. Income level was also closely related to health care utilization: those in the lowest income groups were the most likely to report unmet health care needs and those in the highest income groups were the least likely [5]. From a health policy perspective, it is important to understand the factors that act as barriers to receiving health care because failing to access needed services may result in poorer health and ultimately lead to wider gaps in health inequalities [8].

Self-reported unmet needs are a widely accepted indicator of the difficulties in accessing health care services [8–10]. Unmet needs are routinely collected in major national-level surveys, and the Korea National Health and Nutrition Examination Survey (KNHANES) is no exception. Recently, Kim et al. (2015) used KNHANES (wave 4) to explore determinants of unmet need in Korean adults and found that females, young adults, those with lower educational attainment, and those living outside of Seoul were more likely to report having an unmet health care need [7]. Although this study is a good starting point for understanding the driving factors affecting unmet needs, it fails to distinguish between the origins of such needs. Previous research has shown unmet health care needs can arise for a variety of complex reasons, including personal choice, financial barriers, or lack of services, and each reason for experiencing unmet needs requires a different policy approach [8, 11]. Moreover, determinants for each of these reasons for unmet needs are different. For example, higher educational attainment is associated with a greater likelihood of reporting unmet needs because of personal choice; people with a higher education are less likely to report unmet needs due to financial barriers [10]. Accordingly, researchers have advocated for a more granular measure of unmet health care need for better policy implication rather than focusing on accessibility of health care services [8, 9, 11, 12].

Although there is no consensus on the sub-categories of unmet needs, increasing studies have adopted classifying unmet needs into three categories – availability, accessibility, and acceptability in order to identify various determinants of the different reasons for unmet needs [11, 12]. This study adapted this classification in order to fill existing gaps in the current literature. The aim of this study was to identify factors associated with overall unmet needs, as well as three different sub-categories of unmet needs, in Korean women and men.

This study used data from the Korean National Health and Nutrition Examination Survey (KNHANES), a national population-based survey that tracks the health of Koreans using three components: a health interview, a nutritional survey, and health examination. A variety of indicators are collected on KNHANES including clinical indicators of health, health behaviours, and socio-demographic characteristics [13]. There are 5 different waves of the KNHANES: 1998, 2001; 2005; 2007–2009; 2010–2012. For the present analyses, this study used data from the 2010–2012 (wave 5) questionnaire components. The total sample of the 2010–2012 survey was 25,534 (male: 11,616 and female: 13,918).

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 [18–22]. 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 [29–33]. 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 [36–39]. 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].

This study builds upon previous research by more deeply exploring how socioeconomic factors are associated with unmet needs and the sub-categories of unmet needs-availability, acceptability and accessibility. This study found that women of lower income had a higher level of experiencing overall unmet health care needs. The determinants of unmet need varied depending on the underlying reasons for such an unmet need. Lower income and lower educational level in both women and men increased likelihood of having accessibility-related unmet needs, while younger age groups and women living alone were associated with higher odds of having availability-related unmet needs. Lastly, individuals living in the southeastern regions (i.e., Busan, Daegu, Ulsan, and Gyeonsang province) were more likely to experience overall unmet health care needs. As unmet health care needs are a critical indicator of the health care system in a country, it is important to eliminate any obstacles that prevent access to, or limit the utilization of, health care services. Under the current universal health care system in Korea, women, in particular those of lower income and lower educational levels, have limited accessibility to necessary health care services. A gender-specific health care plan is suggested to reduce the high rate of unmet needs in this group. To reduce accessibility-related unmet needs, increasing services available to the younger age groups needs to be considered.