Post-reunification dental health system preferences associated with multi-stage migration: evidence from North Korean defectors

Since the 1990s, more than 34,000 North Korean defectors have settled in South Korea. Beyond a migrant population, they offer important insights into health system integration in a future reunified Korea. Their oral health is particularly vulnerable due to financial and informational barriers, low oral health literacy, and high unmet dental needs. Their multi-stage migration experiences—across socialist, transit, and market-based systems— might be associated with distinct healthcare preferences. This cross-sectional study included 1,018 participants (800 native-born South Koreans and 218 North Korean defectors). Defectors were categorized into four groups based on length of stay in a transit country (short transit vs. long transit) and length of residence in South Korea (short residence vs. long residence). Outcomes included preferred extent of dental coverage (%), preferred post-reunification healthcare system (national health insurance, integrated North–South hybrid model, or no preference), and preferred level of out-of-pocket (OOP) payments (full out-of-pocket payment, partial cost-sharing, or no out-of-pocket payment). Regression analyses were adjusted for sociodemographic factors including subjective social status (SSS). North Korean defectors showed significantly stronger preferences for expanded dental coverage than native-born South Koreans (aORs: 2.0–3.1, p < 0.05) and preferred lower OOP payments (aORs: 2.5–3.0, p < 0.05). The likelihood of reporting “no preference” for the preferred post-reunification healthcare system was about six times higher among defectors. The short transit/long residence group showed the strongest preference for expanded coverage, whereas the long transit/long residence group most frequently reported no preference. North Korean defectors consistently favor expanded dental coverage and reduced financial burden. The high prevalence of “no preference” could suggest a pragmatic orientation and potential institutional disengagement associated with migration experiences. These findings suggest that financial protection, particularly expanded dental coverage and reduced out-of-pocket payments, may warrant consideration in discussions of post-reunification healthcare policy. The results also indicate that migration-related experiences could be relevant when designing policies intended to improve system acceptability and reduce health inequalities.