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1 Journal of Preventive Medicine and Public Health September 2010, Vol. 43,. 5, doi: /jpmph The Effect of Catastrophic Health Expenditure on the Transition to Poverty and the Persistence of Poverty in South Korea Eun-Cheol Song, Young-Jeon Shin Department of Preventive Medicine, Hanyang University College of Medicine Objectives: The low benefit coverage rate of South Korea s health security system has been continually pointed out. A low benefit coverage rate inevitably causes catastrophic health expenditure, which can be the cause of the transition to poverty and the persistence of poverty. This study was conducted to ascertain the effect of catastrophic health expenditure on the transition to poverty and the persistence of poverty in South Korea. Methods: To determine the degree of social mobility, this study was conducted among the 6311 households that participated in the South Korea Welfare Panel Study in both 2006 and The effect of catastrophic health expenditure on the transition to poverty and the persistence of poverty in South Korea was assessed via multiple logistic regression analysis. Results: The poverty rate in South Korea was 21.6% in 2006 and 20.0% in % of the households are facing catastrophic health expenditure. Catastrophic health expenditure was found to affect the transition to poverty even after adjusting for the characteristics of the household and the head of the household, at the threshold of 28% or above. Conclusions: 25.1% of the households in this study were found to be currently facing catastrophic health expenditure, and it was determined that catastrophic health expenditure is a cause of transition to poverty. This result shows that South Korea s health security system is not an effective social safety net. As such, to prevent catastrophic health expenditure and transition to poverty, the benefit coverage of South Korea s health security system needs to the strengthened. Key words: Catastrophic health expenditure, Health security, Poverty J Prev Med Public Health 2010;43(5):

4 Figure 1. Types of social mobility. Figure 2. Study model.

5 Table 1. Poverty rates and social mobility: households of Korea Welfare Panel Study, 2006, 2008 Unit: number of households (%) n-poverty (N) Total Poverty (P) n-poverty (N) NN 4363 (91.3) PN 0512 (38.9) 4875 (80.0) Poverty (P) NP 0416 (8.7)0 PP 0806 (61.1) 1222 (20.0) Total 4180 (78.4) (21.6) (100.0) NN: persistence of non-poverty, NP: transition to poverty, PN: exiting from poverty, PP: persistence of poverty. Poverty line: equivalised household income below the 50% median line. p-value <

6 Table 2. Characteristics of the study subjects: households of Korea Welfare Panel Study, 2006 n Total 6098 npoverty npoverty 4780 Poverty (2006) Poverty p value Unit: number of households (%) Types of social mobility NN NP PN PP p value Household income (%) Poverty line 200 Poverty line Poverty line Poverty line 50 > Number of working family members 0 Housing tenure Owner occupancy Residential area Metropolitan city Child in family Medical aid Sex of household head Men Age of household head 65> Disabled household head 2961 (48.6) 1818 (29.8) 0956 (15.7) 0362 (5.9) (19.4) 3329 (54.6) 2796 (45.8) 3937 (64.6) 5699 (94.0) 5014 (82.2) 4411 (72.3) 5564 (91.3) 2961 (62.0) 1818 (38.0) 0458 (9.6) (56.7) 2263 (47.3) 2830 (59.2) 4641 (97.6) 4207 (88.0) 3928 (82.2) 4466 (93.4) 0956 (72.5) 0362 (27.5) 0727 (55.2) 0618 (46.9) 0533 (40.4) 1107 (83.9) 1058 (80.8) 0807 (61.2) 0483 (36.6) 1099 (83.3) 2874 (65.9) 1489 (34.1) 0343 (7.9) (57.1) 2083 (47.7) 2523 (57.8) 4269 (98.3) 3908 (89.6) 3692 (84.6) 4091 (93.8) 087 (20.9) 330 (79.1) 115 (27.7) 219 (52.6) 180 (43.2) 307 (73.6) 372 (90.6) 299 (71.9) 237 (56.9) 375 (89.9) 378 (73.8) 134 (26.2) 195 (38.1) 269 (52.6) 220 (43.0) 383 (74.8) 459 (89.9) 354 (69.2) 290 (56.6) 434 (84.6) 578 (71.7) 228 (28.3) 532 (66.0) 349 (43.4) 313 (38.8) 723 (89.7) 600 (75.0) 452 (56.1) 193 (23.9) 665 (82.5) NN: persistence of non-poverty, NP: transition to poverty, PN: exiting from poverty, PP: persistence of poverty. Poverty line: equivalised household income below the 50% median line. Table 3. Proportion of households facing catastrophic health expenditure: households of Korea Welfare Panel Study, 2006 Unit: number of households (%) Poverty (2006) Types of social mobility n Total Poverty p value NN NP PN PP p value Catastrophic health expenditure (T/y 10%) Catastrophic health expenditure (T/y 20%) Catastrophic health expenditure (T/y 30%) Catastrophic health expenditure (T/y 40%) 1531 (25.1) 0848 (13.9) 0591 (9.7) (7.3)0 773 (16.2) 309 (6.5)0 177 (3.7)0 107 (2.2)0 758 (57.5) 539 (40.9) 413 (31.3) 337 (25.6) 646 (14.8) 247 (5.7)0 131 (3.0)0 076 (1.7)0 127 (30.4) 063 (15.1) 046 (11.1) 031 (7.4)0 299 (58.3) 224 (43.7) 173 (33.8) 151 (29.6) 459 (57.0) 315 (39.1) 240 (29.8) 186 (23.1) NN: persistence of non-poverty, NP: transition to poverty, PN: exiting from poverty, PP: persistence of poverty. T: health expenditure, y: capacity to pay (=disposable income - food expenditure). Poverty line: equivalised household income below the 50% median line.

7 Table 4. Characteristics of households facing catastrophic health expenditure: households of Korea Welfare Panel Study, 2006 Unit: number of households (%) Catastrophic health Catastrophic health Catastrophic health Catastrophic health expenditure expenditure expenditure expenditure (T/y 10%) (T/y 20%) (T/y 30%) (T/y 40%) Household income (%) Poverty line 200 Poverty line Poverty line Poverty line 50 > Number of working family members 0 Housing tenure Owner occupancy Residential area Metropolitan city Child in family Medical aid Sex of household head Men Age of household head 65> Disabled household head n (58.4) 1342 (29.4) 0472 (10.3) 0089 (1.9) (12.3) 2462 (53.9) 2110 (46.2) 2703 (59.2) 4276 (94.2) 3895 (85.3) 3685 (80.7) 4227 (92.6) 1531 p-value (19.4) 0476 (31.1) 0485 (31.7) 0274 (17.9) 0626 (40.9) 0868 (56.7) 0686 (44.8) 1233 (80.6) 1424 (93.5) 1119 (73.1) 0726 (47.4) 1337 (87.3) (54.6) 1604 (30.6) 0658 (12.5) 0121 (2.3) (14.4) 2844 (54.2) 2417 (46.1) 3215 (61.3) 4916 (94.2) 4413 (84.1) 4059 (77.3) 4839 (92.2) T: health expenditure, y: capacity to pay (disposable income - food expenditure) (11.2) 214 (25.3) 298 (35.1) 241 (28.4) 428 (50.4) 486 (57.3) 378 (44.6) 721 (85.0) 783 (92.8) 601 (70.9) 352 (41.5) 725 (85.5) p-value (52.9) 1686 (30.6) 0760 (13.8) 0145 (2.6) (15.9) 2983 (54.2) 2535 (46.0) 3429 (62.3) 5152 (94.1) 4588 (83.3) 4170 (75.7) 5067 (92.0) (7.7)0 132 (22.3) 196 (33.2) 217 (36.8) 310 (52.4) 347 (58.7) 261 (44.2) 508 (86.0) 547 (93.4) 426 (72.2) 242 (40.9) 497 (84.2) p-value (51.9) 1739 (30.8) 0816 (14.4) 0165 (2.9) (16.7) 3072 (54.4) 2592 (45.8) 3555 (62.9) 5288 (94.1) 4692 (83.0) 4220 (74.6) 5187 (91.7) (6.3)0 079 (17.8) 140 (31.5) 198 (44.5) 241 (54.2) 258 (58.0) 204 (45.8) 381 (85.9) 411 (93.3) 322 (72.5) 191 (43.0) 377 (84.9) p-value >

8 Table 5. Effects of catastrophic health expenditure on the transition to poverty, result of multiple logistic regression: households of Korea Welfare Panel Study, 2006, 2008 Model I Transition to poverty Model II-1 Catastrophic health expenditure (T/y 20%) Model II Model II-2 Catastrophic health expenditure (T/y 30%) OR 95% CI OR 95% CI OR 95% CI Catastrophic health expenditure Household income (%) Poverty line 200 Poverty line Number of working family members 0 1 Housing tenure Owner occupancy Tenancy Residential area Metropolitan city Others Child in family Medical aid Sex of household head Men Women Age of household head 65 > 65 Disabled household head T: health expenditure, y: capacity to pay (disposable income - food expenditure). OR: odds ratio, CI: confidence interval. Table 6. Effects of catastrophic health expenditure on the transition to poverty by threshold, result of multiple logistic regression: households of Korea Welfare Panel Study, 2006, 2008 Thresholds of catastrophic health OR 95% CI expenditure (T/y ) (%) * 1.52* 1.57* T: health expenditure, y: capacity to pay (disposable income - food expenditure). OR: odds ratio, CI: confidence interval. *p<0.05.

9 Table 7. Effect of catastrophic health expenditure on the persistence of poverty, result of multiple logistic regression: households of Korea Welfare Panel Study, 2006, 2008 Model I Persistence of poverty Model II-1 Catastrophic health expenditure (T/y 20%) Model II Model II-2 Catastrophic health expenditure (T/y 30%) OR 95% CI OR 95% CI OR 95% CI Catastrophic health expenditure Household income (%) Poverty line Poverty line 50> Number of working family members 0 1 Housing tenure Owner occupancy Tenancy Residential area Metropolitan city Others Child in family Medical aid Sex of household head Men Women Age of household head 65 > 65 Disabled household head T: health expenditure, y: capacity to pay (disposable income - food expenditure). OR: odds ratio, CI: confidence interval.

12 1. Kim CY. Theories of Health Security. Paju: Hanul Publishing Co.; 2009, p , Shin YJ. Health care safety net in Korea: issues and policy options. Health Welf Policy Forum 2009; 155: Shin YS, Shin HW, Hwang DK, Kim HI, Kim JS. Establishment of the Health Care Safety Net and Policy Task. Seoul: Korea Institute for Health and Social Affairs; 2006, p , Kim CY, Lee JS, Kang GW, Kim YI. Magnitude of patient s cost-sharing for hospital services in the national health insurance in Korea. Korean J Health Policy Adm 1999; 9(4): Kim SG, Yu SH, Park WS, Chung WJ. Out-of-pocket health expenditures by non-elderly and elderly persons in Korea. J Prev Med Public Health 2005; 38(4): Lim JH, Kim SG, Lee EM, Bae SY, Park JH, Choi KS, et al. The determinants of purchasing private health insurance in Korean cancer patients. J Prev Med Public Health 2007; 40(2): van Doorslaer E, O Donnell O, Rannan-Eliya RP, Somanathan A, Adhikari SR, Garg CC, et al. Catastrophic payments for health care in Asia. Health Econ 2007; 16(11): Organization for Economic Co-operation and Development. Health at a glance 2009: OECD indicators [cited 2010 Feb 9]; 1(1):[1 screens]. Available from: brary.org/content/book/health_glance-2009-en. 9. Suhrcke M, Rocco L, McKee M. Health: a Vital Investment for Economic Development in Eastern Europe and Central Asia. Copenhagen: European Observatory on Health Systems and Policies; 2008, p Xu K, Evans DB, Carrin G, Aguilar-Rivera AM, Musgrove P, Evans T. Protecting households from catastrophic health spending. Health Aff (Millwood) 2007; 26(4): Kawabata K, Xu K, Carrin G. Preventing impoverishment through protection against catastrophic health expenditure. Bull World Health Organ 2002; 80(8): Knaul FM, Arreola-Ornelas H, Méndez-Carniado O, Bryson-Cahn C, Barofsky J, Maguire R, et al. Evidence is good for your health system: policy reform to remedy catastrophic and impoverishing health spending in Mexico. Lancet 2006; 368(9549): Merlis M. Family Out-of-pocket Spending for Health Services: a Continuing Source of Financial Insecurity. New York: Commonwealth Fund; p Somkotra T, Lagrada LP. Payments for health care and its effect on catastrophe and impoverishment: experience from the transition to Universal Coverage in Thailand. Soc Sci Med 2008; 67(12):

13 15. Wagstaff A. Poverty and health sector inequalities. Bull World Health Organ 2002; 80(2): Wagstaff A, van Doorslaer E. Paying for Health Care: Quantifying Fairness, Catastrophe, and Impoverishment, with Applications to Vietnam, Washington, DC: World Bank; p World Bank. World Development Report 2000/2001: Attacking Poverty. New York; Oxford University Press; p World Health Organization. The World Health Report 2008 : Primary Health Care w More than Ever. Geneva: World Health Organization; 2008, p Lee WY. Equity in urban households out-of-pocket payments for health care. Korean J Health Policy Adm 2005; 15(1): Kim ARM. A Study on Poverty Duration and Its Determinants: Focusing on Type of Household [dissertation]. Seoul: University of Seoul ; Kim KS, h HJ. An Empirical study of poverty exit and duration: life table analysis and hierarchical generalized linear analysis. Soc Welf Policy 2009; 36(3): Ku IH, Poverty dynamics in Korea: poverty duration and its determinants. Korean J Soc Welf 2005; 57(2): Ku IH. Socio-economic characteristics of the poor and poverty transition in Korea: since the recent economic crisis. Korean J Soc Welf 2002; 48: Seok SH. Testing for state dependence effects in poverty dynamics. Korean Soc Secur Stud 2007; 23(3): Kim KS. The effect of income transfer on poverty rate. Korean J Soc Welf 2002; 48: Huh SI. Changes in the financial burden of health expenditures by income level. Health Welf Policy Forum 2009; 149: Kim HJ. Household medical expenditure burden of the poor. J Inst Soc Res 2008; 9(1): Son SI. Factors Influencing Catastrophic Health Expenditure of the Poor [dissertation]. Seoul: Seoul National University; Xu K, Evans DB, Kawabata K, Zeramdini R, Klavus J, Murray CJ. Household catastrophic health expenditure: a multicountry analysis. Lancet 2003; 362(9378): Sun X, Jackson S, Carmichael G, Sleigh AC. Catastrophic medical payment and financial protection in rural China: evidence from the New Cooperative Medical Scheme in Shandong Province. Health Econ 2009; 18(1): Lee WY, Shin YJ. Catastrophic health expenditures among income groups in urban households. Korean Soc Secur Stud 2005; 21(2): Huh SI, Choi SJ, Kim CY. Income elasticity of household health expenditure and differences by income level. Korean J Health Policy Adm 2007; 17(3): Lee SY. A Study on inequity in medical care utilization and the proportion of medical care expenditure to income. Korean J Soc Welf Stud 1997; 10: Kim TW, Yang SH, Choi HS, Kim MK, Woo SH, Park EY Poverty Statistics Yearbook. Seoul: Korea Institute for Health and Social Affairs; 2009, p. 7-14, Lee BJ, Kang SK, Ku IH, Kim TS, An SH, Son BD, et al. An In-depth Study of 2006 Korea Welfare Panel Study. Seoul: Seoul National University; p Kim MG, Kim TW. Poverty in Korea: current status and policy issues. Korean Soc Secur Stud 2004; 20(3): Statistics Korea. Health insurance finance and coverage rate. e-national index [cited 2010 Feb 9]; 1(1):[1 screens]. Available from: URL: jsp/potal/stts/po_stts_idxmain.jsp?idx_cd= National Health Insurance Corporation, Health Insurance Review & Assessment Service National Health Insurance Statistical Yearbook. Seoul: National Health Insurance Corporation, Health Insurance Review & Assessment Service; p Shin YJ, Shon JI. The prevalence and association factors of unmet medical need-using the 1st and 2nd Korea Welfare Panel data-. Health Soc Welf Rev 2009; 29(1):

13.12 ①초점

13.12 ①초점 12 2013 Health and Welfare Policy Forum 2 3 4 5 Income Distribution of the Elderly and Desirable Income Support Directions 7 8 9 10 11 12 13 14 15 16 17 A Poverty Solution of Low-lncome Elderly Women