Ethnographic Interviews: Second Generation Transnationalism, 2019

O R I G I N A L P A P E R

Exposure and Exclusion: Disenfranchised Biological Citizenship among the First-Generation Korean Americans

Taewoo Kim • Charlotte Haney •

Janis Faye Hutchinson

Published online: 10 October 2012

� Springer Science+Business Media New York 2012

Abstract Based on fieldwork with a highly uninsured and underinsured Korean American population, this article maps how the current healthcare system in the

United States disenfranchises those of marginal insurance status. The vulnerability

of these disenfranchised biological citizens is multiplied through exposure to dis-

proportional health risks compounded by exclusion from essential healthcare. The

first-generation Korean Americans, who commonly work in small businesses, face

the double burden of increased health risks from long, stress-laden work hours and

lack of access to healthcare due to the prohibitive costs of health insurance for small

business owners. Even as their health needs become critical, their insurance status

and costly medical bills discourage them from visiting healthcare institutions,

leaving Korean Americans outside the ‘‘political economy of hope’’ (Good, Cult

Med Psychiatry 52:61–69, 2001). Through an ethnographic examination of the daily

practice of doing-without-health among a marginalized sub-group in American

society, this paper articulates how disenfranchised biological citizenship goes

beyond creating institutional barriers to healthcare to shaping subjectivities of the

disenfranchised.

T. Kim (&) Department of Anthropology, Chonnam National University, Gwangju 500-757, South Korea

e-mail: [email protected]

C. Haney

Department of Anthropology and Cross-Cultural Studies, University of Houston, Clear Lake,

TX 77058, USA

e-mail: [email protected]

J. F. Hutchinson

Department of Comparative Cultural Studies, University of Houston, University Park,

TX 77204, USA

e-mail: [email protected]

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Cult Med Psychiatry (2012) 36:621-639

DOI 10.1007/s11013-012-9278-7

Keywords Biological citizenship � Risk � Uninsured � Underinsured � Korean Americans

Introduction

In his book The Politics of Life Itself, Nikolas Rose uses the term biological citizen ‘‘to encompass all those citizenship projects that have linked their conceptions of

citizens to beliefs about the biological existence of human beings’’ (2007, p. 132).

He further argues that producing vitality, which he labels the production of

biovalue, has become an important citizenship project. Rose points to a new

biological age in which agents are inclined to see themselves in somatic/biological

terms and become active citizens in the vitalization of that biology through self-care

programs and through collectivizing around shared biological states to demand care.

He suggests that such actions have become ‘‘routine and expected’’ (Rose 2007,

p. 147). However, studies of uninsurance in the United States show that the current

medical payment system creates barriers to care and conditions differential access to

biological citizenship (Becker 2004, 2007; Hadley 2003; McWilliams 2009).

Through detailed ethnographic research with uninsured and underinsured Korean

Americans working in family-run businesses, this article focuses on the daily

practice of doing-without-health and pushes our discussion of the barriers to

healthcare seeking toward an examination of how such barriers cultivate subjec-

tivities of disenfranchised biological citizenship. We also describe, illustrating a

case of ‘‘bio-devaluation,’’ how such disenfranchisement multiplies the study

participants’ vulnerabilities by exposing them to disproportionate health risks and

excluding them from essential care.

Responding to the critique that much of the discussion of biological citizenship is

‘‘programmatic and decontextualized’’ (Whyte 2009, p. 11) as well as calls for more

anthropological research into the uninsured (Horton 2007; Rylko-Bauer and Farmer

2002), this study employed an ethnographic approach in which the researchers were

situated in the same settings where the un/underinsured live and work. By sharing in

these settings, the researchers contextualized the study participants’ multi-layered

predicaments through firsthand encounters—observing the whole fabric of these

predicaments rather than segregated factors. In-depth interviews allowed the

researchers to move between life history narratives and affective accounts of

experiences in current settings.

This paper examines the predicament of the un/underinsured, taking Korean

Americans, one of the most highly uninsured populations in the United States

(Hughes 2002), as an example. Based on a multi-sited ethnography of Korean–

American communities in Houston, Texas, and Los Angeles, California, this study

attempted to delineate the condition of marginal insurance in the United States. In

order to present a comprehensive picture of the uninsured, this study traces health

risks among Korean Americans, from daily life to life in crisis. Studies of risk have

shown that ethnographically contextualized risk provides a window into ‘‘the

primary mechanism through which social inequality is embodied and is visible in

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different prevalences of diseases and outcomes between different social groups’’

(Nguyen and Peschard 2003, p. 457). In particular, anthropological examinations of

HIV risks have exemplified the effectiveness of ethnographically contextualized

risks in linking inequality and ill health (Chapman 2006; Parikh 2007; Farmer

1999). By mapping the connections from an unequal social structure, in which risks

are unevenly distributed, to the disproportionate prevalence of disease, these studies

chart the inscription of inequality on the bodies of the disenfranchised population.

Building on the advances of previous ethnographic studies of risks, the present study

attends to risks as they become visible in the context of the Korean American

community, and attempts to illuminate the embodiment of the social inequality

among uninsured and underinsured Korean Americans by linking exposure to health

risks and exclusion from healthcare.

In order to examine ethnographically contextualized risks, the fieldwork was

conducted within the Korean American community. Choosing community settings

provides three noticeable benefits. First, the field sites enable us to include data

concerning the un/underinsured who have never visited healthcare institutions, an

unfortunately common health-seeking (or unseeking) practice among the un/

underinsured. To date, most qualitative studies of the uninsured have presented

accounts only of those uninsured who finally resort to healthcare institutions. By

conducting research in community settings, we were able to provide more inclusive

data of how healthcare seeking is delayed or stymied among the un/underinsured.

Second, fieldwork within community settings allowed observation of the unhealthy

working and living conditions that many un/underinsured face, giving us a more

complete picture of their predicaments. Although many studies have separately

examined either the impact of social forces on health disparity (Dressler et al. 2005;

Nguyen and Peschard 2003; Wilkinson 2005) or the influence of healthcare

accessibility on the health of the uninsured (Becker 2001, 2004, 2007; Hadley 2003;

Institute of Medicine 2002; McWilliams 2009; Rylko-Bauer and Farmer 2002), few

studies have addressed the peril created by the combination of disadvantageous

social conditions and unequal healthcare. Linking the issues of health disparity and

healthcare inequality, this study shows a comprehensive picture of the consequences

of disenfranchised biological citizenship. Third, fieldwork in community settings

allowed us to see the manner in which the underinsured are also disenfranchised. As

we will see, the underinsured experience many of the same barriers to health found

in the uninsured population. A consequence of these barriers is the double burden of

increased exposure to major health risks and exclusion from necessary healthcare.

When study participants encounter deteriorating health due to these unfavorable

work conditions, their limited access to healthcare makes the process of seeking

appropriate diagnosis and treatment a baffling undertaking, one in which they have

little hope of success. The ill health of the un/underinsured is often exacerbated by

this synergy of exposure to risks and exclusion from care. Thus, by setting our

research within the community in which people suffer and make choices, we are

able to observe how biological disenfranchisement leaves people outside ‘‘the

political economy of hope’’ (Good 2001).

Although Rose acknowledges that ‘‘not all have equal citizenship in this new

biological age’’ (2007, p. 132), his focus remains on the projects of biological

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citizenship. Drawing on Good’s work, Rose argues that these projects grow out of a

‘‘political economy of hope.’’ States enact projects that they hope will bring greater

vitality to their citizens. Biological citizens enact practices that they hope will

increase their health and band with others who they see as biologically similar to

support one another and lobby the government and researchers for greater hope for

their conditions. However, in this paper we argue that the study population is left out

of vitalization projects, invisible to these projects due to the participants’ place in

the employment structure and the current healthcare payment scheme. The high

concentration of small business owners among the first-generation Korean

Americans, conditioned by the limited economic opportunities available to

immigrants, leads to long work hours in risk-laden conditions as well as high

rates of marginal insurance driven by sky-rocketing private health insurance costs in

the United States. Long work hours expose Korean American small business owners

to the health risks of overwork, physical inactivity and stress. These risks are

compounded by limited access to timely preventive measures and appropriate

medical intervention. This combination of exposure to risk-laden working

conditions and exclusion from healthcare increases Korean Americans’ vulnerabil-

ity, in particular, to chronic illnesses including hypertension, high blood cholesterol,

diabetes, and heart disease. These conditions are the bio-devaluation that results

from biological disenfranchisement. Rather than engaging in the hopeful endeavor

of maximizing vitality, the study population engages in the disenfranchised’s

practice of doing-without-health, pinning their hopes on improving their economic

status and their children’s education.

Methods

Findings are based on data collected during a dual-sited ethnographic project. Los

Angeles, California, and Houston, Texas, 1

were selected to evenly represent

different waves of Korean American immigration to the United States. California is

a historic destination for Korean Americans, while Texas is emerging as a new

popular destination; the state’s Korean population increased 43 % between Census

1990 and Census 2000. The first author engaged in participant observation by

regularly attending group activities of four Korean American religious institutions: a

bible study meeting of a Protestant church, a cell group meeting of a Catholic

church, and activities of two Buddhist temples. These religious venues were

successful entry points into the Korean American community for two reasons: first,

religious institutions serve as the main community centers among Korean

Americans (Choi 2010; Jo et al. 2010; Min 1992) and second, Protestantism,

Catholicism, and Buddhism are three representative religious institutions among

Koreans. Along with participation at the religious venues, in-depth interviews with

Korean Americans were conducted. The interviewees include 48 first-generation

1 Fieldwork was conducted in Houston from January 2004 to August 2004 and in Los Angeles from May

2007 to July 2007.

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Korean Americans 2

(18 in Los Angeles and 30 in Houston) with legal status.

Considering the pivotal importance of small businesses among Korean Americans

(Hurh 1998; Min 1996; Min and Bozorgmehr 2000; Park 1997), the first author

visited 32 Korean-owned businesses to conduct observations of working conditions

and in-depth interviews concerning immigrant life. The Korean businesses visited

include beauty supply shops, an alteration shop, gas stations, grocery stores, liquor

stores, sandwich shops, donut shops, a sushi restaurant, a dry cleaning business, a

printing and advertisement business, a florist shop, a Korean funeral home, a

wholesale store, a used tire shop, an accessory booth in the mall, a shoe repair shop,

a frame (traditional Korean style) shop, clothing stores, a bedding shop, a beauty

salon, etc. Engaging in this in-depth qualitative research enabled the authors to

detail how this population experiences biological disenfranchisement.

Findings

The research revealed that the health consequences we see in surveys of the

uninsured are the product of a culture of doing-without-health, where the

marginalized experience a synergy of elevated exposure to health risks and

exclusion from healthcare. Further, this disenfranchisement from U.S. biovitaliza-

tion projects becomes subjectively absorbed as this community practices going-

without-health. In the first part of this section we examine the daily-lived experience

of this elevation in risk exposure. Then we examine how exclusion from care

operates within the studied community settings. Finally, we examine the collusion

of these factors in the lives of our study population. This study investigates two

health risk issues among Korean Americans: First, what kinds of risks Korean

Americans face and their vulnerability to these risks. Second, how risks are

managed or unmanaged in the context of limited access to care. In combining the

first (discussed in the first section of findings) and the second issues (discussed in the

second), this study demonstrates the synergy of exposure and exclusion in shaping

the sufferings of the biologically devalued.

Exposure to Risk

Social and Economic Contexts of Risks

Korean Americans are shut out of biovitalization projects not only by the healthcare

system but also by the employment structure in the United States. Within the

Korean American community, small business ownership leads to many health risks,

yet this is the major source of employment for recent immigrants. One survey

showed a 53 % self-employment rate among Korean–American men in Los Angeles

(Min and Bozorgmehr 2000), and running small businesses is the typical economic

activity in this community. The uneven distribution of economic activities is

testament to the unequal economic opportunities that Korean Americans face after

2 The interviewees’ ages range from 32 to 74 with a mean age of 54.

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immigration. Studies of Korean Americans affirm that small business ownership is

not a voluntary choice; rather, ‘‘Korean Americans were forced by circumstances to

choose careers—in retail or service—that would have been unthinkable had they

remained in Korea’’ (Ablemann and Lie 1995, p. 144). Circumstances include:

institutional barriers disregarding educational attainments and professional experi-

ences in South Korea, linguistic barriers, and already saturated economic

opportunities in the host country (Ablemann and Lie 1995). Small businesses are

one of the few economic opportunities available to Korean Americans. The present

study shows that this typical form of economic participation exposes Korean

Americans to health risks such as overwork, physical inactivity, and stress on a daily

basis. Although Rose suggests habits that maximize biovalue are now expected and

those who ‘‘refuse to identify themselves with this responsible community’’ are

problematic persons (2007, p. 147), as we will see, small business ownership

precludes engaging in the most commonly expected American health habits:

sufficient sleep and relaxation, stress avoidance, exercise, and preventative medical

care.

Overwork and Physical Inactivity

In a society where citizens are commonly exhorted to ‘‘take time for themselves,’’

for the sake of mental and physical health, many Korean small business owners find

themselves without any spare time. Korean businesses are typically concentrated in

small scale retail endeavors such as grocery stores, convenience or liquor stores,

beauty supply shops, restaurants, etc., characterized by long hours of operation.

Many Korean businesses are open 7 days a week. A statement in a Korean

newspaper, explaining the merits of a dry cleaning business over other common

business pursuits, implies the near-ubiquity of a seven-day work week among

Korean Americans: ‘‘The dry cleaning business has the advantage of not opening seven days’’ (emphasis added, Kang 2007). According to the field data, the average

business hours of the businesses enumerated above are 11 (grocery), 16 (liquor

store), 18 (convenience store), 10 (beauty supply shop), 11 (restaurant), and 13 (dry

cleaning). The three convenience stores in this study are open from 7 a.m. to

12:30 a.m., 5:30 a.m. to 12:00 a.m., and 5 a.m. to 11 p.m., 7 days a week,

respectively. Korean Americans tend to work long hours at their businesses to

compensate for the low-profit margins of the typical Korean businesses (Ablemann

and Lie 1995). As a direct result of the demanding work schedules, Korean

Americans are often exposed to overwork and physical inactivity.

When asked how much time they exercise per day, most participants responded

that their demanding work schedule does not allow them to reserve time for

exercise. They insisted that they ‘‘cannot’’ exercise rather than ‘‘do not.’’ The story

of Shin, 3

a 39-year-old man, who runs a convenience store in Houston, points out

some of the serious health risks of small business ownership. He works in the store

from 7 a.m. to 12:30 a.m. (17.5 hours), 7 days a week. He bought the convenience

store with a relatively small down payment. In order to pay the mortgage every

3 All names are pseudonyms.

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month, he and his wife spend most of their time at the store. When the interviewer

visited around 10 p.m., Shin was there alone and looked exhausted. He said his wife

was at home taking care of their two children. When asked about exercise, he

expressed his frustration:

I was a tennis player when I was in Korea. Every Sunday I played tennis all

day long with members of our tennis club. I still really want to play sports. In

front of our apartment there is a golf range. Every morning when I come here,

I think about playing golf. But I can’t… After coming here [to the United States], I just work from the time when I open my eyes and to the time when I

close my eyes…I’m in a very bad condition now. I feel very severe fatigue, but I can’t recover from that. I feel like my whole body and mind are stuck on

the bottom. I think the fatigue that I can’t recover from is because I’m always

in a state of tension at work and because the working time is too long. 4

In the 48 interviews, Korean Americans reiterated this sense of inescapability

regarding overwork and physical inactivity. Prior studies have also pointed to long

hours as a major difficulty for Korean Americans (Ablemann and Lie 1995; Min

1990, 1998). In addition to the health risks of the demanding work schedule

necessary to keep the businesses profitable, the manner in which this time is spent

creates additional risks. For many Korean Americans, these long hours are spent in a

state of stress.

Stress

Korean Americans face a significant amount of work-related stress. The stress that

Shin describes as ‘‘being in a state of tension’’ is a regular part of their daily

economic activities. Our data identified this stress as multi-layered, chronic, and

intensive. Stress is causally layered. It is situated in anxieties caused by the

following: (1) a variety of face-to-face interactions with culturally unfamiliar and

heterogeneous customers, (2) high levels of criminal victimization, and (3) the

financial precariousness of small business ownership. Our informants reported that

they suffered from a persistent state of tension throughout their daily economic

activities, and associated this tension with the ‘‘unfamiliarity’’ and ‘‘unexpected-

ness’’ they often face in their businesses.

When asked about the stresses of immigrant life, informants commonly noted a

‘‘language problem.’’ However, observation data showed that this ‘‘language

problem’’ does not just indicate limited fluency in English. Rather, when the

language problem is contextualized in Korean Americans’ everyday economic

practice, the problem refers to the bewildering array of unfamiliar interactions the

business owners encounter during their business hours, ranging from conducting

ordinary transactions with other ethnic groups to handling complaints and quarrels.

This ‘‘language problem’’ is a source of considerable stress to Korean Americans,

who have often not participated in small business activities before immigration and

in their homeland may have had limited exposure to other ethnicities. Even though

4 All interviews were conducted in Korean and translated into English later by the first author.

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the ‘‘unfamiliarity’’ associated with this ‘‘language problem’’ is mitigated by the

respondents’ length of stay in the host land, they report the ‘‘unexpectedness’’

associated with face-to-face customer encounters continues to be a source of

tension.

A lawsuit in Washington D.C., in which a customer sued a Korean-owned dry

cleaning store for his lost pants and asked for $67.3 million (Sabar and Lee 2007),

circulated widely throughout the community, revealing the high level of tension

with which Korean Americans anticipate quarrelsome situations with their

customers. In addition to anxiety about conflict with customers, Korean Americans

also report greater stress associated with their increased anxiety about crime.

Robbery and theft are not rare at Korean businesses. Min’s (1996) survey of a

Korean ethnic newspaper showed that, from 1987 to 1991, 20 Korean Americans in

Los Angeles County were the victims of homicides associated with armed robberies.

In the present study, 7 of 48 Korean Americans who participated in in-depth

interviews said that they had experienced at least one robbery. The stress associated

with anxiety about robbery is severe and not limited to those who have themselves

experienced a robbery. Tragic stories about Korean victims circulate widely in the

Korean community, increasing worry about victimization.

This generalized anxiety is evidenced by the numerous strategies put forth by our

informants operating businesses in high-crime areas for preventing robberies from

becoming homicides. Yoon, a Korean man in Houston who runs a used tire shop,

warned that ‘‘if you encounter robbers, you should not look at their faces. If they

think you can remember their face, they will kill you.’’ Joo, a 50-year-old female

who runs a fabric store in Korean Town, Los Angeles, said, ‘‘When I encountered a

robber a few years ago, I picked up cash from the register and showed the cash in

my raised hands. He just took it.’’ Kim, who operates a convenience store in

Houston, gave his safety plan: ‘‘I will escape from the counter to the inside room

[there is a small room behind the counter in his convenience store] if I get robbers.

But I need to be careful. I should escape before they pull out a gun.’’ Min’s (1990)

study on Korean American business problems corresponds with this data. Based on

a survey of 557 Korean Americans in Los Angeles, the study found vulnerability to

armed robbery along with long work hours as one of the major problems for Korean

American businesses. It is noteworthy that many of the Korean Americans who now

run businesses in lower crime areas were also exposed to the similar levels of

anxiety about crime in previous businesses. As Korean Americans accumulate

enough capital to start a new business, they often move their businesses from

higher-crime areas to safer ones. 5

This widespread pattern of changing businesses

marks crime anxiety as one of the leading sources of stress in the Korean American

community.

Studies of social change and health have shown that lack of familiarity with

social environments results in greater stress that can significantly affect health

outcomes (Dressler 1999; Janes 1990; Kelleher et al. 2006; Steffen et al. 2006). In

5 For example, Bae, a 58-year-old Korean American man in Houston, enumerated his previous

businesses as he moved from a grocery store and a beauty supply shop in a minority community to a

Korean grocery and his current dry cleaning business in an upper-class community.

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other words, ‘‘[t]he more closely individuals approximate in their own behaviors the

shared expectations of local cultural models of these domains, the better their health

status’’ (Dressler and Bindon 2000, p. 247). Korean immigrants, far away from the

familiar realities of their homeland, are exposed to high levels of stress. The radical

transition of migration, unfamiliarity of daily transactions with customers, and

unexpected situations in their businesses, including armed robbery, put an

insurmountable distance between Korean Americans’ taken-for-granted notions of

daily life and the realities of immigrant life. This insurmountable distance results in

intolerable stress among Korean Americans.

Along with the stresses associated with daily transactions in their businesses, the

financial precariousness of small businesses ownership exposes Korean Americans

to an additional layer of stress. This typical stress associated with small business

ownership weighs more heavily on Korean Americans because of their limited

opportunities in the United States. With limited English language skills and

qualifications that are not understood or valued in the US in a saturated employment

market, small business ownership is for many the only employment option. Even

when their businesses are unsuccessful or unprofitable, Korean Americans have

difficulty adopting alternative economic strategies. Instead, their strategic response

is limited to changing businesses within the typical scope of Korean businesses,

going from a grocery store to a restaurant or from a beauty supply to a dry cleaning

establishment.

In the interviews, the Korean American participants clearly demonstrate their

awareness of the high risk (overwork, physical inactivity, and stress) associated with

their economic activities. Yet, the participants also unambiguously state the

unavoidability of these risks; for these Korean Americans, practicing healthful

behaviors—the ‘‘lifestyle changes’’ so widely urged in American media—is not an

option. In the narratives, this inevitability is often expressed as ‘‘we know that, but

it’s not avoidable.’’ The exposure to risks in daily life often lasts until their

retirement. Constrained by limited economic opportunities, Korean Americans are,

despite their awareness of the risks, forced to stay in deleterious employment

environments. The intensive exposure to multiple health risks over a prolonged

period is exacerbated by exclusion from healthcare.

Exclusion from Care

Following previous ethnographic studies’ emphasis on the role of institutions in

shaping immigrants’ subjectivities (Becker 2007; Horton 2004; Ong 1996), we also

focus on the role of the U.S. healthcare system in molding the study population’s

disenfranchisement from biological citizenship. In line with Becker’s findings

(2007), detailing how the uninsured who visit healthcare institutions experience

‘‘discouragement’’ from using healthcare services, we find that the un/underinsured

outside medical settings also experience discouragement. Even those who have

never visited hospitals in the United States, a category into which many Korean

Americans fall, experience discouragement through the payment system embedded

within the current healthcare system. Long-term uninsured status, a common pattern

among Korean Americans working in small businesses, and widely circulated

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stories of financially devastating medical bills build an unreachable distance

between Korean Americans and healthcare institutions. Underinsured Korean

Americans, despite their allegedly insured status, also encounter discouragement

from the current healthcare system. For them, managed care, in particular the high

out-of-pocket costs, serves as the discouraging agent. With tight budgets,

underinsured Korean Americans, fearing the high cost of medical care, avoid

visiting doctors’ offices as much as possible. These experiences of discouragement

among un/underinsured Korean Americans carve a specific subjectivity in which

healthcare is perceived as ‘‘a project not for us.’’ In this molding of subjectivity and

health-seeking practice, a disenfranchised biological citizenship emerges, one

unable to engage in vitalization and vulnerable to the excess suffering of

preventable health crises.

The Uninsured

Studies of healthcare access have shown an elevated rate of uninsured among

Korean Americans, ranking them as the most highly uninsured population among

Asian Americans (Brown et al. 2000, 2007; Chin et al. 2000; Hughes 2002; Shin

et al. 2005). Even though the estimated percentages of uninsured Korean Americans

vary according to age groups and survey methods (ranging from 34.1 to 52 %),

these studies confirm that Korean Americans are highly uninsured compared to the

national average (16.3 % in 2010). Significantly, the uninsured rate for Korean

Americans under 65 years is 48.7 % (Shin et al. 2005, cited in National Institute of

Health 2006) and 52 % for those between age 18 and 64 (Hughes 2002). In the

present study, 22 out of 48 informants report that they do not have health insurance.

Furthermore, the in-depth interviews reveal that healthcare access is even more

limited than indicated by these statistics: because uninsured Korean Americans,

with a few exceptions, have been uninsured the entire length of their residency in

the United States and the underinsured’s access to healthcare is not discernible from

that of the uninsured.

Among the 22 informants who are uninsured and under 65 years of age, most (19

participants) responded that they have not had health insurance since immigrating to

the United States. Korean Americans’ narrow scope of occupations—self-employ-

ment—explains this long-term lack of coverage. According to a report of the 2005

California Health Interview Survey (Brown et al. 2007), Korean Americans have a

significantly lower rate of employment-based health insurance coverage (38.2 %)

compared to other sub-populations such as European Americans (66.8 %), Asian

Americans (59.3 %), and African Americans (50.3 %). The majority of Korean

Americans who do not have access to employer-subsidized coverage have to buy

private insurance. According to the Census 2000, Korean Americans’ median

income is $42,010/year. Taking into account the skyrocketing costs of average

annual premiums, more than $15,000 for employer-sponsored family coverage

(Kaiser Family Foundation and Health Research and Education Trust 2011), many

Korean Americans clearly cannot afford costly private health insurance.

In this long-term non-insurance situation, many Korean Americans forego

preventative care, diagnoses, and treatments. For example, Jung, a 64-year-old man

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who recently retired from running a grocery in downtown Houston, has been

uninsured during his entire 29-year residence in the United States. In an interview,

he expressed his excitement about the coming year in which he would finally be

insured by Medicare, enumerating medical exams and treatments he planned to have

in the next year. A survey conducted in Los Angeles examining healthcare

utilization by Korean Americans has made clear their limited access to healthcare

(Shin et al. 2005). Korean Americans show noticeably lower rates of annual

physician visits (2.8) compared to other population groups such as European

Americans (5.92) and African Americans (3.70). Korean Americans also exhibit a

significantly lower rate of physician visits than their counterpart-population in South

Korea (10.7) where coverage is mandatory through national health insurance. In

particular, Korean Americans under 65, who are the most likely to be uninsured,

show the lowest rate (1.8) of annual physician visits. This lack of access to wellness

demonstrates Korean Americans’ exclusion from the ranks of citizens whose

biovalue is cultivated by the state.

The Underinsured

Due to the high out-of-pocket cost, Korean Americans with private health insurance

are not exempt from the practice of forgoing needed preventive measures and

medical intervention. They tend to buy insurance with high deductibles to reduce

the financial burden. Kim, a Korean American woman who operates a beauty salon

in Los Angeles, has a family plan covering her four family members that has a

$5000 deductible. When asked about healthcare utilization, she responded that, even

though she pays $399 monthly for the family plan, she has never been to the

hospital, fearing the high cost of the deductible. Underinsured Korean Americans

face a dilemma: they have health insurance, but they cannot use it. When asked why

they pay for health insurance if it does not increase their access to healthcare, study

participants responded with comments epitomized by one reply: ‘‘It would reduce

the financial burden, when I get a deadly disease.’’ Multiple interviews with

underinsured Korean Americans 6

revealed that for many study participants health

insurance is synonymous with crisis insurance, not an avenue to access care but

protection for their families in the eventuality of an expensive life-threatening crisis.

In order to accurately map the dilemma of underinsured Korean Americans, we

need to examine how managed care, the structuring principle of the American

healthcare system, is situated within the Korean American community. Since the

1973 HMO Act was passed, the issue of cost control has provided the ground for

managed care’s hegemony over the healthcare system in the United States (Dutton

2007) and deductibles have been one of the main tools proponents of market-based

healthcare reform used to reduce healthcare costs (Hoffman 2006). However, when

contextualized in the everyday lives of underinsured Korean American, deductibles

mean real barriers to access. With an average income of $42,010 a year, most

Korean Americans need strict budgets to cover their monthly expenses. The study’s

6 Among the 48 interviewees, 9 are categorized as underinsured. When they are added to the 22

uninsured, a total of 31 are uninsured or underinsured.

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ethnographic data show that the spending priorities in these budgets are usually

arranged in accordance with the Korean American dream. Economic opportunity

and better education for their children are the main reasons motivating Korean

Americans to cross the Pacific (Hurh 1998). On this basis, business expenses,

housing costs, and education are prioritized. In a context with limited incomes and

the high costs of medical care, Korean Americans are forced to place medical

expenses near the bottom of their priorities. Using high-deductible insurance plans

is seen as a severe budget disruption. Most who have these insurance plans do not

use them for routine care, preferring to pay cash at clinics in Korean Town without

informing their insurance companies for fear of increasing premiums. For example,

Son, a 42-year-old Korean American woman reported that she had had a medical

exam at a clinic in Los Angeles Korean Town and paid the $250 bill in cash. Over

the course of the fieldwork, no informant reported using or hearing of someone

using his or her insurance for preventive measures. Rather widely circulated disaster

stories of, for example, the bankruptcies of uninsured cancer patients, lead Korean

Americans to buy high-deductible plans—crisis insurance—in an attempt to avoid a

combined catastrophe of health and financial crises.

For many study participants, high deductibles served as the discouraging agent

from buying any health insurance at all. When asked about regular check-ups, Kim,

a 54-year-old Korean man who operates a convenience store in Houston, and who

has been uninsured during his entire 28-year residence in the United States said:

There is no such a thing as check-up for us [Korean Americans]. The hospital

is a place where we go when we feel pain, isn’t it? If I have health insurance, it

would be a different matter. But even the American insurance system is not

good. American insurance often has a one thousand or two thousand

deductible [here, he points to the deductible he would pay at one hospital

visit]. Who would buy it? It’s too expensive.

Among most Korean American business owners, health insurance is synonymous

with high deductibles. As Kim’s statement illustrates, high deductibles leave Korean

Americans with the belief that ‘‘even though you have insurance, you have to pay a

great deal when you visit the hospital.’’ Caught between two bad choices, Korean

Americans either buy under-insurance as a form of crisis insurance or decide to be

uninsured with the sentiment, ‘‘who would buy it?’’ In either case, they are left to

engage in a daily practice of doing-without-health.

The Culture of Doing-without-health

Rose (2007) suggests that there are two directions in the vitalization project of

biological citizenship, one coming from above as the state and institutions attempt

to enact measures that will increase their citizens’ vitality and the other coming

from individuals as they incorporate this project into their subjectified reality

through accepted habits of good health. In the case of the disenfranchised, these

behaviors often do not occur. As we see in our study population, the un/

underinsured avoid visiting healthcare institutions as much as possible. Signifi-

cantly, the observation and interview data show that healthcare barriers are not

632 Cult Med Psychiatry (2012) 36:621–639

123

simply a question of denied or limited access to healthcare, but a different

subjectified reality for the un/underinsured, the biologically disenfranchised. Ong’s

notion of ‘‘cultural citizenship’’ provides a plausible framework for explaining this

phenomenon (1996). Ong argues that citizenship is ‘‘a cultural process of ‘‘subject-

ification,’’ in the Foucaultian sense of self-making and being-made by power

relations that produce consent through schemes of surveillance, discipline, control,

and administration,’’ shaping a population’s ‘‘cultural practices and beliefs’’ (1996,

pp. 737–738). Ong suggests that in the subjectification process in the United States

social institutions play crucial roles. This argument is embraced and elaborated by

Becker (2007) and Horton (2004), who found that, among social institutions, the

healthcare system plays a crucial role in shaping cultural citizenship. In an

examination of the uninsured who visit the hospitals, Becker found that they were

discouraged from frequenting healthcare institutions, resulting in avoidance of

healthcare among the uninsured.

These direct and indirect interactions with the unequal healthcare system

construct a subjectivity of a disenfranchised biological citizenship. This subjecti-

fication results in a culture of avoiding medical care among Korean Americans. In

an interview, Yoon, a 49-year-old uninsured woman in Los Angeles, explained,

‘‘Seeing a doctor in America is too expensive a matter.’’ Even though she has never

visited the hospital and never paid for health services in the United States, she had

an assertive and negative attitude toward American healthcare services. Like Yoon,

informants in this study attached a shared assertion to hospitals: ‘‘too expensive to

go.’’ They discuss healthcare in the United States as if it were located in some

remote place beyond their reach. In the course of 48 interviews, we witnessed a

‘‘distance’’ placed between the Korean Americans and the American healthcare

institutions. This distance is a specific health-seeking belief as well as a practice,

disciplining the avoidance of American healthcare. Korean Americans’ distance

from valued forms of American citizenship is further seen in the common practice

of crossing the Pacific Ocean for medical care.

Fearing high medical costs, 7

Korean Americans even visit South Korea to receive

medical exams and treatments. In this context, Asiana Airlines, a major South

Korean airline, sells tour packages to South Korea for medical exams (Moon 2008).

As demonstrated by one South Korean hospital reporting it had examined 566

Korean Americans during a 13-month period (Lee 2010), many Korean Americans

take this far alternative route to medical care. When asked about their latest check-

up, a number of interviewees in this study said that it was ‘‘a few years ago in

Korea’’ when they visited their home country. In the field, the interviewer

encountered numerous tales of Korean Americans visiting South Korea for surgery.

Crossing the Pacific Ocean for care is a testament to the disenfranchised biological

citizenship conferred in the United States. Unfortunately, avoiding medical care and

seeking help far away only amplify the serious health risks resulting in the negative

health outcomes seen among Korean Americans.

7 When Korean Americans decide to visit healthcare institutions, the population tends to visit Korean

American clinics usually located in Korean Town. However, using clinics in Korean Town is also

impeded by insurance status and costly medical bills.

Cult Med Psychiatry (2012) 36:621–639 633

123

Unmanaged Risks under Limited Accessibility to Care

Although the phrase ‘‘disenfranchisement from the project of vitalization’’ sounds a

bit anemic, this disenfranchisement results in very real and systematic social

suffering. Chronic diseases cannot be managed by doing-without-health. When the

study population develops chronic illnesses such as high blood cholesterol,

hypertension, and diabetes, illnesses that require regular preventive measures and

timely medical intervention, the population suffers enormously. For example, Roh,

a 58-year-old man in Los Angeles, had recently had his first check-up since

immigrating to the United States 15 years ago. After running his own businesses for

more than 10 years, he was working for a business owned by a Korean friend. Roh’s

job did not provide health insurance, and he had been uninsured since his

immigrating to the United States. After developing symptoms of numbness around

his mouth and chronic, severe exhaustion, Roh finally went for a check-up. The

physician who reviewed the results of medical exams informed him that he had high

blood pressure, high cholesterol, and an enlarged heart. Roh has no way of knowing

how long he has had these conditions. Roh is similar to many uninsured or under-

insured Korean Americans, who tend to visit healthcare facilities only when their

symptoms become unmanageable. Unfortunately, major chronic illnesses such as

high cholesterol, hypertension, and even diabetes often reach a serious phase

without noticeable symptoms. The study participants are more likely to experience

these disorders because of the elevated risks—overwork, physical inactivity, and

stress—encountered while running small businesses. Since the participants work in

small businesses and therefore have restricted access to preventative care, they are

more likely to let these diseases go untreated and unmanaged. 8

Studies examining the consequences of uninsurance (Ayanian, et al., 2000;

Becker 2001, 2004; Institute of Medicine 2002) have demonstrated its detrimental

impact on diagnosing health problems as well as its negative influence on managing

ill health. We see this detrimental impact detailed in the case of Yoo, a 56-year-old

man. Since immigrating 22 years ago, Yoo has been uninsured. He was first

diagnosed with heart disease when he visited a clinic in Korea Town, Los Angeles,

five years before the interview. At the time of his diagnosis, he was running a

wholesale store in downtown Los Angeles. Although he suffered from sleepless-

ness, weight loss, thirst, and dry cough, he delayed visiting a doctor’s office for fear

of a high medical bill. At the time, his business was experiencing financial

difficulties. He said, with a bitter smile, ‘‘I was using my body to block financial

loss.’’ At the clinic, the doctor prescribed medications. Yoo took the medications for

a year but by the end of the year his symptoms had returned and worsened. He could

only sleep sitting up, and the pigmentation of his face darkened. The worsening

symptoms forced him to give up his business and finally persuaded him to visit the

University of Southern California (USC) medical center. At the medical center, he

8 Many issues frame accessibility to healthcare among immigrant populations, including linguistic and

cultural ones. For Korean Americans (a highly uninsured and underinsured population) health insurance

status is the critical issue shaping their practice of not seeking healthcare. Linguistic and cultural barriers

do little to explain why many Korean Americans do not visit clinics in Korean Town run by Korean

American doctors.

634 Cult Med Psychiatry (2012) 36:621–639

123

had an angiogram for the first time and was informed that his left ventricle was not

pumping blood properly. Between his first visit to the clinic in Korea Town 5 years

before and his visit to the USC medical center 2 years later, his heart disease had

been poorly managed. With no insurance, he reported that he was reluctant to pursue

follow-up care. This lack of follow-up care has resulted in a deteriorating heart

condition.

The literature warns of premature death among the uninsured (Hadley 2003;

Institute of Medicine 2000; McWilliams 2009). The uninsured ‘‘who have been

hospitalized for heart attacks are over 25 percent more likely to die while in the

hospital’’ (Becker 2004, p. 259; Hadley 2003). The ethnographic data from this

study demonstrate that difference in treatment at the hospital does not cause these

different outcomes, but rather differences in care that occur in community settings

do. In order to see the unfortunate synergy that occurs when people do-without-

health, let us turn to a final narrative. Park and his wife ran a burger shop near

downtown Houston. He opened the shop 7 days a week, 10 a.m. to 9 p.m. from

Monday to Saturday and 12 a.m. to 8 p.m. on Sunday. In response to high crime

rates, a fence was built covering the front part of the shop. Due to security issues

and the size of the shop, customers could not enter. The customers placed and

received their orders through a small window in the fence. Park cooked and served

up the orders while his wife tended the register. After 5 years of this life, he died of

acute myocardial infarction. On the day before he died, he worked until 9 p.m.

Early the next morning, he complained of chest pain and difficulty breathing. His

wife called 911, and he was sent to the hospital. He died there 4 hours later. The

hospital was the first and the last healthcare institution he visited in the United

States. When the interviewer visited the shop with a key informant, his wife was

running the shop with the help of her grown children. The interviews with Park’s

wife and the key informant, Park’s friend, clearly show that Park had limited

opportunities to manage his health risks. We cannot know if Park would have died if

he had been able to engage in the vitalization project of enfranchised biological

citizens, but we do know that his disenfranchisement made his death more likely.

Conclusion

Exemplified in this study is an un/underinsured population with significant

healthcare needs brought about by increased exposure to health risks and exclusion

from appropriate healthcare. We see in this study how the costs of bio-devaluation

increased morbidity and mortality among the un/underinsured. These consequences

are not limited to the first-generation Korean Americans. The National Health and

Nutrition Examination Survey (NHANES 1999–2006) found that among those with

elevated cholesterol and diabetes, the uninsured were more often undiagnosed, and

those with hypertension and elevated cholesterol more often had uncontrolled

conditions (Wilper et al. 2009). While these health conditions are observed among

the insured, they are even more prevalent among the uninsured. Although the

current study examines how these outcomes proceed from the particulars of

disenfranchised biological citizenship among the first-generation Korean

Cult Med Psychiatry (2012) 36:621–639 635

123

Americans, evidence like the NHANES study makes clear that this bifurcation is

continually embedded within the American healthcare system.

The current healthcare system in the United States does not allow the un/

underinsured to participate in biovitalization projects. The system discourages

preventive care and delays visits to physicians, and diagnosis and treatment.

Consequently, the un/underinsured do not feel connected to the healthcare system

and use it only in dire circumstances. Social institutions, such as health insurance

and managed care, play a crucial role in crafting subjectivities of disenfranchised

biological citizenship and shaping a culture of doing-without-health. If the state

determines what citizenship is and is not by drawing this line both at the

institutional level (insured versus uninsured) and the internal level (inclined to seek

care versus disinclined to seek care), the current healthcare system in the United

States ‘‘separate[s] those whose lives are to be enhanced from those whose lives are

not worth preserving’’ (Das and Das 2007, p. 87). Such line drawing crafts expectant

biological citizens and disenfranchised, devitalized citizens contained outside the

political economy of hope. If citizenship is the process through which we delineate

citizen from non-citizen, when we investigate of biological citizenship we must

commit ourselves to studying the consequences borne by the disenfranchised.

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