Health Resilience and Inequality in Healthcare Utilization: A Longitudinal Comparison Between North Korean Refugees and South Korean Residents.

Introduction: This study compared the long-term patterns of healthcare utilization and health status of North Korean refugees (NKRs) and South Korean residents following the refugees' resettlement in South Korea. Methods: This population-based cohort study utilized customized data from the National Health Insurance between 2007 and 2022. The NKRs were matched in a 1:5 ratio with South Korean residents from the general population based on year of first healthcare utilization , age, sex, income level, disability status, and region. The final study sample comprised 23,836 NKRs and 118,280 South Korean residents. Healthcare utilization was measured by the length of stay (LOS), number of outpatient visits, and total medical expenditure. Health indicators were assessed using the Charlson Comorbidity Index and number of primary diagnoses. The Generalized Estimating Equation was used to analyze temporal trends, and the Cox proportional hazards model for survival analysis. Results: NKRs incurred significantly higher total medical expenditures compared to South Koreans during the initial seven months following resettlement. Subsequently, expenditures decreased but gradually increased over time, similar to the pattern observed for South Koreans. Discussion: The key finding indicated that NKRs exhibited higher healthcare utilization and disease burden compared to South Korean residents, during the initial post-settlement period. Although this disparity appeared to stabilize over time, refugees continued to demonstrate higher medical service use and poorer health status in the long term. Notably, the Cox regression analysis revealed a significantly lower risk of mortality among refugees compared to South Koreans.