originally published in KoreAm Magazine
Korean Americans have one of the highest uninsured rates in the United States. Now, looming health care reform could change their lives—maybe save some, too.
By Kathleen Wentz
You could still see the dried blood on Sudok Choi’s bandaged left ear. A week before, the owner of Koryo BBQ in Oakland had been in a car accident, which had also left her arm in a cast. But it wasn’t her wounds that most worried Choi; it was the cost of her health insurance.
“It’s my biggest financial concern right now,” she said through the translation of her 19-year-old son, Tae Kim, as she waited for customers inside her restaurant on a recent Saturday afternoon. Currently, 58-year-old Choi shells out about $1,600 a month for private insurance to cover herself, her husband, son and mother. And the economic downturn has only made that cost more burdensome. “Business has gotten really slow lately and it’s gotten really hard,” she said, her empty restaurant starkly demonstrating.
As a small business owner, Choi says she has little choice; she’s forced to either pay exorbitant amounts for private insurance or risk going uninsured. Given the current hard times her business is suffering, lately, she’s considering taking that risk, she said. If she does, she’ll join the growing number of Americans priced out of a health care system whose costs are ballooning out of control while also denying millions of people access to care.
Choi’s case isn’t unique to the American experience. But it turns out that Korean Americans are disproportionately impacted by the troubling state of the health care industry. That’s because Korean Americans have one of the highest uninsured rates in the United States at about 31 percent, according to the Kaiser Family Foundation, based on data collected between 2004 and 2006. As a racial group, Hispanics have the highest rate, at 32 percent. For Koreans, the lack of insurance is primarily due to the fact that so many are self-employed or work at small businesses. (About 53 percent of the U.S. population receives health insurance through their employer.) In essence, it’s the cost that prevents them from getting care.
As a result, many Korean Americans are at risk for chronic diseases—not to mention financial ruin. Increasingly, they seek care in South Korea, where a universal health care system means it’s cheaper to buy a $1,000 plane ticket to fly thousands of miles away to see a doctor than it is to see a physician down the street. To boot, those, like Choi, who are insured, still face high deductibles and out-of-pocket expenses. Language barriers and inadequate translation services also impede the ability of doctors to effectively communicate with patients. In some cases, it’s even led to death.
Now, with the prospect of a major health care overhaul looming, there’s an opportunity to dramatically alter this troubling picture. As of press time, members of Congress were still massaging three different proposals, with a final bill expected on President Obama’s desk possibly by Christmas. Late last month, Senate Majority Leader Harry Reid (D-Nevada) announced that a public option—meaning insurance that’s administered and funded by the government similar to how Medicare works—will be in the Senate’s final bill, despite initial uncertainty about its inclusion. All of the bills would require everyone to be insured or face penalty, and would ban private insurers from denying coverage because of pre-existing conditions.
The impact of these changes could be far-reaching for all Americans, and especially Koreans. “When we say that Korean Americans have the highest uninsured rate among Asians, and this rate is twice the rate of the United States, it’s saying that Korean Americans desperately need health care reform,” said Dr. Ricky Choi (no relation to Mrs. Choi), who heads the pediatric department at Asian Health Services in Oakland and resides on the board of the National Council of Asian Pacific Islander Physicians.
“Having a public option will add competition to the health insurance market, help bring costs down, and therefore allow more people to have access to the health care system,” he said. “Without health insurance, you can’t work, you can’t go to school, you can’t plan for the future.”
Yet Koreans continue to be largely uninformed about how the country’s health care system works, and, like many Americans, of how pending legislation might affect them. Mrs. Choi, who immigrated to the United States in 1982, said she was confused as to which of her insurance companies—car, life or health—would be paying her hospital bills. Navigating such complex bureaucracy would be difficult for anyone, let alone someone with limited English-speaking ability.
And she wasn’t any clearer on health care reform. Choi admitted she didn’t really understand what reform would mean for her, but said it would be unfair if her taxes were going to be raised as a result. However, when told that reform could mean cheaper insurance for her, Choi said she’d “jump at the chance.”
So might 46 million other Americans.
That’s how many people in this country don’t have health insurance, according to 2008 census data. Such individuals often go years without seeing a doctor and must resort to visiting the emergency room in times of desperation. It’s hardly an effective way of getting care.
“No one would be able to say that you can treat cancer successfully by episodic ER visits,” said Dr. Choi.
What about treating a heart murmur condition that requires a pacemaker?
“I don’t have insurance, and I don’t have a primary care doctor,” said Joseph Cho, 23. “What I do have is a pacemaker. What I will need is surgery” to replace it.
About every six months, Choe visits the emergency room of a county hospital in the San Fernando Valley section of Southern California, waiting about three to six hours to be seen by a doctor—“and that’s if I arrive two hours early,” he said. If he needs a prescription, he has to wait another three hours. “Usually, I reserve one whole day dedicated to the county hospital,” he said.
Choe, studying computer science at Glendale Community College and who up until recently was also working part-time at an internet company, was diagnosed with a heart murmur at age 4. At that time, he received a pacemaker, which regulates his heartbeat, and has had one ever since. Each one, as well as the battery, lasts between six to 10 years. He is also on three different medications. His medical care at the county hospital has resulted in about 10 bills, each running about $1,300, he said, but he’s only had to pay between $60 to $100 of each. The cost of his care is subsidized through a Los Angeles County program called ORSA, which covers medical care at Department of Health Services facilities, on an outpatient basis only.
The Los Angeles native said he has been following some of the debate about health care, and despite the difficulty of telling truth from fiction, he said he is in favor of reform. “I know all around this country, there are people like me who have a pre-existing medical condition who need insurance, but have difficulty getting insured,” he said. “I think everyone should have the right to a healthy life.”
But under our current health care system, Korean Americans, who are predominantly immigrants and own or work for small businesses, remain particularly vulnerable.
One 55-year-old owner of a small clothing store in Flushing, New York, said that she has gone without insurance since emigrating from Seoul 10 years ago. “My friends tell me that it costs $80 each time you go to the doctor,” said Minjung, who did not want her last name published. “I am not sure what I would do if I got sick,” she added, as she coughed violently.
Mihi Yi, a florist in Union City, New Jersey, said, fortunately, she and her husband do have private insurance, but that they cannot afford to buy it for their two employees. “It is better set up in Korea,” said the 52-year-old, referring to the country’s universal health care system. “In America, people with a lot of money have medical care, but people like me who are middle class and small business owners, we pay a lot of taxes and fees and we don’t get any benefits. We are worse off than the poor.”
“I think Korean Americans are emblematic of what is the issue with health insurance in the United States,” said Dong Suh, associate director at Asian Health Services and chair of the board of directors at the Korean Community Center of the East Bay. “They make too much money to qualify for public programs, but are too poor to afford health insurance. It’s hard for anybody who’s not offered insurance through employment or public programs to purchase insurance on their own. That’s the dilemma they’re in—they’re vulnerable to great financial risk if they get sick and if they’re hospitalized or need long-term care of some kind.”
And, yet, oftentimes, Korean Americans sacrifice their health for other expenditures, like their children’s college funds. For others, it may also be a case of lacking a tradition of regular doctor visits and preventive care.
Charlie Jun has never had health insurance. Even though his late father was a manager for a Korean market and his mother worked at a mainstream retail-clothing store, they did not receive insurance through their employers.
“The Korean mentality is you can’t afford to get sick,” said the 25-year-old Jun, who emigrated from Korea with his family at age 3. “I knew if I got hurt or sick [as a child], I wasn’t going to the hospital. The yearly check-up was non-existent. I didn’t know what that was. I thought that was a luxury white people had.”
Now, a graduate student studying British literature at California State University, Northridge, Jun said he got used to walking off aches and injuries. “I’m still the same status, where I can’t afford to get hurt.”
It was only in recent years, while living and working in South Korea as a university instructor, that he realized he didn’t have to live this way. Jun suffers from scoliosis, a curvature of the spine, and would often touch his back in pain. One day his friends asked why he didn’t just see a doctor.
“They didn’t see why I would be living in pain,” he recalled. “They thought it was ridiculous.”
Jun did end up visiting the doctor’s office in Korea and said, for $60, he received first-rate care that included a three-hour appointment with physical therapy. For that cost in the United States, he said, a chiropractor saw him for five minutes.
Not only are people being shut out of the current U.S. health care system because of the exorbitant costs, but those who are willing to pay for private insurance are being denied coverage.
After graduating from business school a few months ago, Dean Choe, a Los Angeles resident who asked that this pseudonym be used to protect his privacy, lost the affordable health coverage he received as a graduate student through his university. While the 30-year-old could have purchased COBRA to extend his coverage, that would have cost him $650 for the first month and $450 each month thereafter, he said.
Then, when Choe, who works as an independent business consultant, tried to get insurance privately, he was turned down. After losing his mother to a long battle with cancer, he had started seeing a therapist. The company saw that the therapist had prescribed him an anti-depressant and considered that a pre-existing condition. “I mean, I am an otherwise very healthy 30-year-old male in pretty good shape,” said Choe. “I don’t know much about this health care debate, but it just seems like something is wrong when people who need help the most don’t get it.
“Now I have no insurance, and I can no longer see a therapist, and I can no longer take [my anti-depressant].”
Notably, the United States is the sole industrialized nation that allows private for-profit companies to provide primary health care insurance. Many countries offer a mix of public and private nonprofit options.
Because of this for-profit mentality, oftentimes, the bottom line, versus a doctor’s opinion, dictates what procedures and treatments are covered by insurance. Winston Chung, a child and adolescent psychiatrist based in San Francisco, said that, sadly, this approach has affected the way that some doctors treat patients. He said patients sometimes aren’t able to receive appropriate medication if an insurance company doesn’t cover it, or some doctors, concerned about the high cost of hospital stays, will prematurely discharge patients.
Yanghee Park, whose family does have employer-provided health insurance, questioned whether this concern for the bottom line delayed her daughter’s diagnosis of a back problem. When the 15-year-old daughter complained of severe back pain about a year ago, Park took her to see a physician in Los Angeles’ Koreatown, even though she lives nearly 20 miles away in Torrance. The immigrant from Korea wanted to be able to communicate with a doctor in her native language and couldn’t find a Korean-speaking doctor in her plan closer to where the family lives. She said, initially the doctor just told the family to “wait and see” if the teen’s back would feel better. But Park said, meanwhile, her daughter was in so much pain, she would cry.
It would take six months from the initial visit to the doctor to the final diagnosis by a specialist who, after X-rays, found a herniated disk. “As a mother, I felt really, really upset, not being able to get the care my daughter needed,” said Park. “I felt, what’s the difference between being insured and not being insured, when I’m still in this situation? If the doctor had connected her to a specialist early on, maybe we would have been able to get treatment started earlier. When I spoke to the doctor about this, how it’s not fair, he said it’s a problem with insurance and not within their control.”
The irony is, even after the diagnosis, her daughter’s medical condition is still not resolved. She was prescribed painkillers, and now Park is thinking about seeking out an acupuncturist for treatment—a form of alternative care that would not be covered by insurance.
With experiences like this, it’s not surprising that, increasingly, Korean Americans are opting to seek health care in Korea. In fact, Korea has been marketing to attract foreign patients in an effort to help cash-strapped hospitals and boost the overall economy. Last year the New York Times reported on the building of Health Care Town on the island of Jeju, a proposed medical hub that was to boast 370 acres of clinics, along with surrounding golf courses and beaches.
And it’s not just Koreans going on so-called “medical tours“ to countries like South Korea, India, Singapore and Thailand. Last year, an estimated 750,000 Americans traveled abroad for various medical procedures including hip replacements and dental work that cost only a fraction of what it would in the United States. The wait time for procedures and follow-up also tend to be much quicker overseas.
Many Korean immigrants and nationals who have experienced both the American and South Korean health care systems overwhelmingly report the superiority of the latter. Because citizens there have universal coverage, it only costs about 3,000 won, or about $2.50, for a regular doctor visit, according to Dong Suh of Asian Health Services. Generic prescriptions cost about 1,500 won (about $1.25). One Korean national living temporarily in the United States with her family said it cost about $200 per month, in Korea, to insure her entire family of five, when it costs that much per person in the United States.
Beyond the issue of cost, there is also a certain ease for limited-English-speaking Korean Americans to seek care in Korea. Indeed, one of the most pressing issues for Korean Americans and other immigrant communities is having proper translation services. While the Civil Rights Act of 1964 stipulates that all physicians, clinics and hospitals that receive federal funding be required to provide interpreters, the law isn’t always strictly enforced. “The prevailing attitude is it’s the responsibility of the patient to bring in people” who can interpret for them,” said Suh.
Technically, a doctor is supposed to know the person’s language needs beforehand and have an interpreter there when the patient arrives. But “that is not the norm,” said Suh, whose own community clinic does offer services in 10 different languages and caters to mostly immigrant populations in the Bay Area’s Alameda County.
In some cases, language barriers lead to substandard care, and even death. Stella Han, patient navigator supervisor at Asian Health Services, recalled the story of a liver cancer patient, who came to the clinic a few years ago. Though he had known about his condition for more than six years, the 56-year-old did not seek treatment earlier because he had no health insurance and did not speak English. As his condition worsened, he went to the county hospital, but was turned down because he did not have a referral to see a specialist. When the patient finally made it to Asian Health Services, Han arranged that day for a doctor to see him. The doctor gave him the referral he needed, but by the time he was admitted, it was too late. He died a few weeks later.
That’s why immigrant advocacy organizations like the National Korean American Service & Education Consortium have pushed for health care reform proposals to include provisions that address linguistically- and culturally-appropriate care. They’re urging lawmakers to incorporate the Health Equity & Accountability Act of 2009 into health care reform, in order to equip the system with bilingual workers, for example.
Working with a broad coalition of organizations, NAKASEC, a supporter of the public option, has also been a leader in pushing to advance other health reform policies that would benefit the Korean American community—including eliminating the current five-year waiting period for legal immigrants to access Medicaid and making sure all immigrants regardless of status are eligible for insurance. They have the support of U.S. Rep. Mike Honda (D-San Jose), chair of the Congressional Asian Pacific American Caucus, who along with other like-minded lawmakers, has penned letters to key players in the reform debate in the House of Representatives and the Senate. The letters urge the inclusion of these immigrant-related provisions into the final health care bill.
Honda has also argued against Senate Finance Chairman Max Baucus’ much-publicized proposal to exclude undocumented immigrants from purchasing health insurance coverage and prevent legal immigrants here less than five years from accessing tax credits. “American taxpayers are already paying for the health care costs of immigrants when they use emergency and social services,” said Honda in a statement released by his office. “Americans currently pay $56 billion annually to ensure the uninsured’s use of emergency care. The fiscally prudent response, then, would be to seize the opportunity to have the uninsured help pay for their own health care, instead of spreading the cost to others.”
But Hemi Kim, the D.C. director for NAKASEC, said it will be an uphill battle to get provisions to improve health care access for all immigrants into the final legislation. “We know immigrants are a wedge issue,” she said. “So the fight isn’t just about a policy fight, but how do we make sure people see immigrants as not [a group to] be scapegoated, but to be embraced. There’s a policy fight and there’s a public-messaging fight.”
She added, “They are among us, too,” referring to the undocumented population. “They are one-fifth of the Korean American community. So, it’s important for all members to have access to health care, including the undocumented.”
Meanwhile, health care costs are continuing to rise. Government spending on health care has now reached 16 percent of our GDP—double what it was 30 years ago—and is projected to reach 18.4 percent, or $3.6 trillion, by 2013. “Every year the premiums and insurance go up at a pace faster than inflation,” said Dr. Ricky Choi. “So I think the numbers of uninsured will continue to grow. And certainly for Korean Americans, if cost is a big obstacle, which I think it is, then that percentage will only grow as well.”
Kim and other advocates are urging Korean Americans to contact their legislators and share their stories, so they can help change the public discourse on the issue.
“It’s very important that their voices are heard,” agreed Marguerite Ro, deputy director of San Francisco-based Asian & Pacific Islander American Health Forum, and a member of the Department of Health and Human Services advisory committee on minority health. “They pay taxes, they contribute to the well-being of, not just the Korean American community, but the nation overall.”
While a bill may not be a silver bullet to solving all our health care woes, its passage could be a crucial step toward better and cheaper access to health care for all Americans. That would help people like Sudok Choi, the small business owner from Oakland, focus on treatment of her recent injuries—instead of worrying about the cost of paying for it.
Additional reporting by Julie Ha, Smriti Rao and Ellis Song.