This study examined how the economic crisis in late 1990s and following neoliberal restructuring differently influenced the Korean people's life expectancies across different socioeconomic states. The intriguing result of this study is that the gap of social inequalities in life expectancy exists in Korea. The differences in life expectancy by education level appear to be more extreme than those previously reported based on Western societies.[13–22].
From the outset, we hypothesized that the gap of life expectancy at age 40 and ASDR across educational levels became widened as Korea went through the structural adjustment process imposed by IMF. Because the main thrust of the process was neo-liberalism, and deteriorating social inequality in health and mortality has been documented in a number of industrialized countries where neo-liberalism was expanded after their economic recession[1, 2]. Based on the findings of this study, we are not able to simply determine that mortality disparity across levels of education among all Korean adults worsened over the study period. However, at least some pieces of evidence clearly indicate that the relative disparity in life expectancy at age 40 and ASDRs became worse among certain groups of Korean adults during and after the period of tremendous economic and social turbulence. They were the working aged Korean males and females (aged 40 to about 55), and Korean females were more victimized than males by the economic crisis or the introduction of neo-liberalism.
These results are quite comparable to outcomes of Russian crisis rooted from its political and economical turbulence during early 1990s. The Russian elementary-educated people showed tiny or almost no gaps versus the college-educated (below 3-year difference at age 20 in men; almost no difference in women) before crisis, but the elementary subgroups of both gender surprisingly lost 4-year life expectancy at 20 in a decade while the college ones gained about 6-year. On the other hand, this study shows that Korean elementary-educated people had already tremendous gaps versus the college-educated even before the crisis (around 10- year life expectancy differences at age 40 in men and 4-year in women in 1995). However, the Korean elementary-educated still gained (3.1-year in men: 4.4-year in women, from 1995 to 2010) without reversal in their life expectancy at 40 in a decade although the college-educated acquired many more years (4.79 in men: 6.10 in women from 1995 to 2010). Korea exhibits much worse socioeconomic disparities in life expectancy between two subgroups nearly a decade after crisis compared to follow-up outcome in similar years after crisis in Russia. As mentioned above, a twofold mechanism by which neo-liberalism can increase health inequality can be considered: commodification of medical services and enlarged socioeconomic polarization. We believe the latter played a more important role than the former in widening mortality gap across educational groups among the working aged, particularly female Koreans. Of course, the commodification of once-publicly owned goods (such as energy, telecommunication, transportation and education) took place in full-scale right after the inception of IMF-proposed adjustment program[24, 25]. However, at least the speed of health sector commodification was not accelerated being protected by the Korea National Health Insurance (NHI) system and the increased government spending on health services. Although the NHI often becomes the subject of criticisms regarding its limited coverage range and shows inequalities of health service utilization between different income groups, there is overall consensus that it has gradually reduced inequity in healthcare financing across income and occupational groups by expanding benefits (decreased premium and increased coverage) for Koreans of lower socioeconomic status. Further, statistics show that governmental expenditure on health and social security has rather grown since 1997. For instance, the share of public health-related expenditure out of total government spending increased from 6.24% in 1995 to 12.42% in 2005[11, 26]. During this period, there was 665% increase in the Medical Aid budget, and according to the Korean government statistics, almost no change was found in the share of health care-related expenditure out of the total consumer expenditure since the economic crisis (from 4.6% in 1996 to 4.9% in 2005). Therefore, it is more likely that the increased socioeconomic polarization due to the expansion of neo-liberalism after the economic crisis was the major cause of increased mortality disparity discovered by this study.
Then why has the inequality in mortality increased only in working aged Koreans since the economic crisis? Labor market flexibility was one of the major conditions required by the IMF restructuring program. Under this condition and subsequent legalization of layoffs during corporate restructuring, companies, regardless of their size, began to actively utilize human resource policies that replaced regular workers with non-regular workers. The less educated or unskilled manual workers in their 40s and 50s were often the prime subject of layoffs or replacement. Before the economic crisis, employment in a company, regardless of the size of the company, meant lifetime employment in Korea. The concept of non-regular or part-time worker rarely existed in the country, and the most important factor that determined worker's salary was the seniority system. As the labor market became flexible and layoffs became legally supported, most companies began to downsize themselves by eliminating uncompetitive workers whose salary was relatively high but whose task was easily replaceable. The less educated or unskilled manual workers in their 40s and 50s who used to be protected by the lifetime employment inevitably became the victim of such transformation in the labor market. Increased insecurity in the job markets of the 40s and the 50s quickly worsened the share of non-regular jobs and a rapid surge in the size of the working-poor population, apart from the traditional poor. Then it gave rise to worsening inequalities and socioeconomic upheaval among all poor Koreans of working age[24, 27]. Under the process of such economic restructuring, downward social mobilization was most prevalent among the 40s and the 50s[5, 27, 28], and, in turn, this phenomenon might have caused aggravated mortality inequality over time in these age groups as found in this study.
Another reason might be from inequalities in work. In Korea, education usually tends to determine future occupation. Lower educational level may act as a strong barrier to achieving a better occupation. Therefore the lower educated groups (less than high school level) tend to occupy manual labour jobs compared to the higher educated groups (higher than college level). After the economic crisis, work has been thoroughly intensified, based on the employers’ intention to increase productivity or, in other words, profits. Intensified work increases the physical demands placed on workers and can deteriorate the workers’ health, especially among the manual labour jobs. Therefore, the effects of socioeconomic disruption would have operated through work.
Our results showed that the adverse consequence of economic crisis regarding social differences in mortality by the levels of education was more pronounced for females than for males. It suggests that Korean women were victimized by the economic crisis to a much larger extent relative to their male counterparts. For centuries, Korea has been a male dominant society where husbands are the major bread winners and wives occupy more domestic roles. Since the economic crisis, women, particularly among the lower social classes, were driven out of the house and had to participate in the labor market due to a rapidly increased risk of unemployment and wage cutoffs of their husband. Because these women workers were unskilled, they mainly occupied jobs with very low wages and little or no job security[29, 30]. Labor force participation itself, in general, could promote female health, given the positive relationship between work and health. However, when the low-educated women of extreme financial need entered the labor market, and had to continue their roles as housewives, it is more likely that the labor force participation harmed health rather than promoting it. Thus, Korean women of low socioeconomic position had to experience the double jeopardy of household economy collapse and working in an unstable position under unhealthy working environment.
Our study has the following limitations. Firstly, as the data from the census and the national death files were not matched by individual person, misclassification of educational variable is likely in the census and national death data, which would be referred to as a numerator-denominator bias. Secondly, the use of education as a proxy for social class in this study might not be an accurate indicator for measuring true social class differentials. However, as the previous Korean studies showed that educational differences were more strongly related to the inequalities in health, therefore, the limitations of education would make the result less likely to be biased[31–36]. We also could not consider the changes of the educational system from 1995 to 2005. Education in Korea, especially college, had developed over the years. Therefore status of each education background may not be the same over the periods, but exactly who those individuals are and what specific risks they face cannot be determined with the available data. Thirdly, this study includes trends for the life expectancy measurement among Korean population only consider five different time periods (1993, 1995, 2000, 2005, and 2010). However, this data set supports our hypothesis by showing the typical changes among three different time periods: before (1993,1995), in the middle of economic crisis (2000), recovering period (2005,2010).
In conclusion, our study discovered that the harms were concentrated among low educated people, especially among working-aged population and women compared to elderly and men, during the late 1990s' economic decline and following neoliberal restructuring in Korea. These results may give lesson to current commodification process of medical services taken place in Korea, which have consisted of launching a government-level task force team to allow private hospitals modifying their legal status from non-profit to profit-making foundations as well as trying to make the private medical insurance as to supplement NHI. Given these processes of commodification of medical services, even though slow and gradual, it is very likely that social disparity in health such as life expectancy will be enlarged soon in Korea.