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국가의 국민건강보호의무와 건강보험제도에 대한 법적 연구

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The concepts of Constitutional right to Health is yet unfamiliar one. The Article 34(1) of the Constitution, 'All peoples shall be entitled to a life worthy of a human beings.', and Article 36(3) of the Constitution, 'The health of all peoples shall be protected by the State.' are provisions on which Constitutional right to Health is based. Since the Constitution has guaranteed right to Health, the State became responsible to the protection Health of peoples, and the peoples gained the right of security of Health toward State.

In this study, I analyzed the current situation and problems of the Legal Institution of the "National Health Insurance System (hereafter NHIS)" with reviewing the birth and historical development of NHIS on the premise that it is one of the important institutions of social insurance.

The purpose of the "National Health Insurance Act" is to improve the people's health and promote social security by providing the people with insurance benefits for, prevention of disease and injury, medical examination, medical treatment, rehabilitation and childbirth, death, and improvement of health. The first public medical insurance act enacted in 1963 and according to the Amendment in 1976 became the health care insurance compulsorily. The national health insurance act enacted in 1999 and amended recently in 2013.
Though the NHIS has contributed to the marked improvement in health conditions, it has some problems to be solved. It faces difficulties with a low coverage rate, a rapid cost expansion, and a inequality of burden. Based on the analysis, I suggest several improvement points of NHIS.

First, the NHIS achieved universal coverage only 12 years after its introduction. Nevertheless, payments for non-covered services remain large compared to other countries, and the co-payment rate is high.
According to the OECD, Out-of-pocket payments (co-payments and the cost of non-covered services) by patients is the third highest in the OECD countries. Especially, co-payment rates for out-patient care is the highest among the 20 OECD countries that require co-payments.
Thus, I suggest that the security level of the NHIS should be enhanced continuously and security enhancement centered on the necessary medical care. Also, the NHIS ought to provide almost the same guarantee level of low-income as the medical care of welfariat. In addition, as a mid-and long-term policy issue, I suggest that the introduction of Sickness Benefit Program.

Second, perhaps the biggest challenge facing the NHIS is the rapid increase in its expenditure. During the decade to 2011, per capita health expenditure in Korea rose at an 9.3% annual average rate, the fastest in the OECD countries. Funding for rising health expenditure will have to come from some combination of higher NHIS fee, tax revenue, and out-of-pocket-payments by patients and private health insurance.
However, expanding out-of-pocket payments, by raising co-payment rates or reducing the coverage of NHIS, would not be desirable as it would reduce access to health care. While private insurance can provide additional resources, relying mainly on private insurance to finance the increase in health expenditure would not be appropriate, given the already high level of private spending. Also, continuing to rely primarily on the NHIS fee for health expenditure would tend to hold back employment and growth.
Thus, I recommend to raise up the support of public finance and introduce new consumption tax to impose. The expiration of the law on financing NHIS in 2016 could provide an opportunity to begin rebalancing the financing of health care toward tax revenue.

Third, because the insurance levy system separated into the workplace subscribers and the regional subscribers, the workplace subscribers claim that they burden much more than the regional subscribers. Also, the regional subscribers on the other hand feel that the present levy system is unfair.
Thus, it is necessary that the reform of the levy system to impose the NHIS fee based on the income according to the principle of burden equality. Also, the NHIS fee ought to be imposed on the other kinds of income, for example the financial income etc, rather than the earned income.

Finally, to maximize the will and interests of subscribers (general peoples) from the point of view of financial democracy, the structure of decision-making should be autonomous and independent mechanism by minimizing the influence of provider (medical doctor, hospital or pharmaceutical industry).
To do so, making it essential to rationalize and re-adjust the functions of the "Health Insurance Policy Deliberative Committee (under the Ministry of Health and Welfare)" and the "Fiscal Management Committee (under the National Health Insurance Service)". Also, the "National Health Insurance Service" and the "Health Insurance Review and Assessment Service" need organizational consolidation.
제주대학교 대학원
대학원 법학과
Awarded Date
2014. 2
Table Of Contents
제1장 서 론 1
제1절 연구의 목적 1
제2절 연구의 범위와 방법 3
1. 연구의 범위 3
2. 연구의 방법 4
제2장 국가의 국민건강보호의무에 대한 헌법적 근거 5
제1절 건강과 질병의 개념 5
1. 건강의 개념 5
2. 질병의 개념 11
제2절 국민건강보호의무의 의의 13
1. 국민건강보호의무의 근거규정 13
2. 국민건강보호의무의 내용 15
3. 국민건강보호의무의 법적성격 18
4. 국민건강보호의무 관련 법령 23
제3절 사회국가원리와 국가의 국민건강보호의무 24
1. 사회국가원리의 개념 24
2. 우리 헌법의 사회국가원리 25
3. 사회국가원리와 국민건강보호문제 27
4. 사회국가원리 실현수단으로서 공적 건강보험 27
제4절 주요국의 공적 건강보험제도 29
1. 공적 건강보험제도의 유형 29
2. 영국의 국민보건서비스체계 30
3. 독일의 건강보험제도 33
4. 미국의 공적 건강보험과 의료보험개혁 38
5. 시사점: 미국의 의료보험개혁이 갖는 의미 45
제3장 우리나라 건강보험제도의 개관 47
제1절 국민건강보험법제의 변천과정과 특징 47
1. 국민건강보험법제의 변천과정 47
2. 국민건강보험법제의 특징 50
제2절 국민건강보험의 기본구조 53
1. 적용대상: 전 국민 53
2. 보험급여 53
3. 관리운영체계 56
4. 재 정 56
5. 진료비지불제도 57
제3절 국민건강보험의 보장성 관련 현황 58
1. 국민건강보험의 보장성 수준 58
2. 국민건강보험의 보장성 확대 과정 59
3. 국민건강보험의 재정 현황 및 전망 62
제4장 건강보험제도의 운영실태와 법적·제도적 문제점 64
제1절 국민건강보험의 보장성 관련 문제점 64
1. 의료사각지대를 유발하는 높은 본인부담률 64
2. 보험급여 구조상의 문제: 3대 비급여(Big3)의 존재 67
3. 국민건강보험 재원 총량의 부족 79
제2절 보험료 부과체계의 이원화에 따른 부담의 형평성 문제 82
1. 보험료 부과체계의 현황 82
2. 보험료부과체계의 문제점 83
제3절 보험료 결정에 있어서 가입자 자치의 문제 85
1. 재정운영위원회의 역할 및 기능 약화 85
2. 재정운영위원회 위원의 대표성 문제 88
제4절 진료비심사의 부실운영으로 인한 재정 누수의 문제 89
1. 국민건강보험 진료비심사의 의의 89
2. 국민건강보험 및 주요외국의 진료비심사체계 91
3. 국민건강보험 진료비심사의 문제점 95
제5장 국민건강보험의 법적·제도적 발전방안 98
제1절 국민건강보험의 보장성 강화 98
1. 보장성 강화 목표: 건강보험 보장률 80% 98
2. 비급여서비스의 건강보험 급여화 추진 99
3. 요양급여비용에 대한 본인부담비율의 인하 101
4. 상병수당제의 도입 102
제2절 국고지원 확대를 통한 국민건강보험의 재정건전화 103
1. 국고지원 방법상의 개선방안 104
2. 소비기준 건강세의 신설을 통한 국고지원 재원 확보 105
제3절 부과체계 단일화로 보험료 부담의 평등원칙 실현 106
1. 보험료 부과체계 단일화의 기본원칙 106
2. 보험료 부과체계 단일화에 따른 고려사항 106
제4절 보험료 결정과정에서의 가입자자치 실현 108
1. 재정운영위원회를 가입자위원회로 전환 108
2. 재정운영위원회 등의 위원선임 방법 개선 108
제5절 국민건강보험의 진료비 청구 및 심사체계 개선 109
1. 국민건강보험의 진료비 청구절차 개선 109
2. 진료비 심사기관과 보험자의 기능적 통합 110
제6장 결 론 113
참고문헌 119
Abstract 133
제주대학교 대학원
고관혁. (2014). 국가의 국민건강보호의무와 건강보험제도에 대한 법적 연구
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