국민건강보험의 보장성 강화를 위한 요양급여제도 개선방안에 대한 연구

Abstract

Since the early 2000s, when the application of National Health Insurance was mandated to all citizens and insurance carriers were integrated, discussions on the expansion and augmentation of coverage have been ongoing. Even today, enhancing coverage is one of the most contentious issues regarding National Health Insurance. However, despite consistent enforcement of government policy to enhance coverage and considerable investment in health insurance, the coverage rate of health insurance for incurred medical charges covered has been stagnant in the low 60 % for the past decade. It is incontestable that enhancing National Health Insurance coverage has constitutional justification since the Korean Constitution adopts the Social State Principle as one of its fundamental constitutional principles. Even so, enhancing National Health Insurance coverage within the realistic context of limited health care resources and insurance finance necessitates the establishment of principles and standards derived from a social consensus regarding the specific health care services that should be included in National Health Insurance benefits, determination of the health care services that should be provided first, and establishment of standards for the measures that should be undertaken to reduce patient co-payments. Therefore, there is the need for examination regarding the limitation of improving coverage of National Health Insurance provided by a constitutional state and approaches to ensure procedural justification based on a democratically-derived consensus over policy decisions regarding coverage augmentation. Such research should start from an investigation of problems and formulation of improvement options for the health care benefit system with the aim of determining the level of National Health Insurance coverage. Thus, the purpose of the present study is as follows: examination of the health care benefit system, which function as legal and systematical means to increase National Health Insurance coverage regarding medical expenses; analysis of the deviation of the current legal system; identify options to ameliorate such problems. Based on the understanding of the health care benefit system that form the legal and systematic basis for National Health Insurance coverage enhancement, measures for such can be proposed as follows: Providing principles and standards for coverage improvement should be established, professional evaluation methods should be implemented, and the Deliberation Committee of National Health Insurance Policy should be administered democratically.