국민건강보험법상 요양급여제도에 관한 헌법적 고찰 : 건강보험 보장성 강화를 위한 법제 개선방향을 중심으로

다국어 초록 (Multilingual 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. Moreover, there should be measures to protect the rights of health care providers, since transferring health care services as insurance benefits within the National Health Insurance system inevitably restricts the freedom of health care providers operating medical institutions.
Therefore, there is the need for examination from a constitutional perspective 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 and concomitant health care benefit standards that regulate such system. Thus, the purpose of the present study is as follows: examination of the health care benefit system and its standards, 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 from constitutional standards; identify options to ameliorate such problems; and generation of measures to secure sustainability of coverage expansion based on the premise of limited resources.
This thesis consists of three main sections: Chapter 2 (Social State Principle and the Demand for Coverage Expansion); Chapter 3 (Importance and Issues of Health Care Benefit System regarding Improving Health Insurance Coverage); and Chapter 4 (Direction of Health Care Benefit System Development to Enhance Sustainable Coverage).
Chapter 2, by examining the constitutional significance of the Social State Principle and the structure that actualizes the right to public health as a medical security system within the social security system and investigating the significance of public medical security and limitations of national intervention, provides the theoretical background of this study. Based on such examination, a theoretical foundation is provided for establishing the principles and standards for coverage improvement. Through such theoretical background, an overview of the historical development of Korea’s National Health Insurance is provided as the foundation, based on which coverage improvement of the National Health Insurance has become the prevailing major health policy agenda. In addition, to analyze the problems of coverage improvement that the National Health Insurance is currently facing, the chapter examines the significance, current status, and specific methods of coverage improvement of the National Health Insurance system, factors to consider for coverage improvement, and policy-based efforts and limitations for coverage improvement.
Chapter 3 analyzes the significance and provisions of the health care benefit system under the National Health Insurance Act, as well as the normative system of the health care benefit standards that regulate the system. Moreover, a specific normative structure for improving National Health Insurance coverage via the standards for health care benefits is examined to comprehend the system’s significance and importance and standards for coverage enhancement. Furthermore, based on the aforementioned role and importance of the health care benefit standards, the major issues of the health care benefit system with regards to coverage improvement are analyzed in three aspects, namely increasing benefits and adjusting co-payments, guaranteeing optimal medical charge and evaluating the cost of health care benefits.
In Chapter 4, the principles and standards for National Health Insurance coverage augmentation is first examined as a premise to generate options to resolve the aforementioned problems of the system, followed by improvement measures. Also, the limitations of coverage augmentation and complementary measures for the health care benefit system are examined in the light of the following factors: restricted application of arbitrary non-benefit care and its appropriate management, reorganization of the medical expenses payment system, supplementation through private commercial health insurance, and reasonable role sharing.
The results of this research can briefly be summarized as follows; Increasing National Health Insurance coverage specifically indicates enhancement of the level of benefits by expanding the range of National Health Insurance benefits or reducing patient co-payments. Therefore, coverage under the National Health Insurance is determined by the range and level of health care benefits which refer to the core medical service provided. The types and items of such health care benefits are listed in the benefit inventory announced by the Minister of Health and Welfare. For each item of health care benefit, a set, fixed cost of health care benefit and patient co-payment are provided based on the treatment-based payment system. As such, the range and items of health care benefits are ultimately finalized by cost evaluation of the health care benefit by the Health Insurance Review and Assessment Service.
The norms that form and regulate the specifics of the health care benefit system provided by the National Health Insurance, such as the benefits’ subject and range, their cost calculation and bearing, and evaluation thereof, are referred to as the standards for health care benefit. The standards for health care benefit regulate the range of medical services included in National Health Insurance benefits based on medical grounds and cost-effectiveness. Thus, the standards play a role in determining the priority of benefits and adjusting the level of benefits when extending the range of benefits, assessing the cost of benefits, and setting the co-payment level. The standards also become the basis for effective management of limited resources through cost evaluation of benefits. Moreover, the health care benefit standards have significance in providing the legal and systematic foundation for National Health Insurance coverage improvement functioning and restricting the fundamental rights of health care providers due to compulsory inclusion in the National Health Insurance system based on the system of medical institution designation.
Enhancing National Health Insurance coverage cannot be achieved merely by increasing the rate of health insurance coverage. Based on modern National Health Insurance functions and roles, enhancing coverage indicates actualizing universal medical security; that is, when medical service is necessary to maintain, restore, or improve health, any eligible individual in such need shall receive corresponding medical service in quality (range of benefit) and quantity (level of benefit). However, due to realistic limitations such as limited medical resources and finances, enhancing coverage of the National Health Insurance should move towards guaranteeing access to essential medical services. So doing will enhance access to medical care by reducing the financial burden incurred from the use of medical service and achieve the purpose of the National Health Insurance, i.e., prevent those covered from becoming socially disadvantaged on account of onerous medical expenses.
To enhance essential medical services coverage, the services should first be determined and included within the National Health Insurance benefit range, followed by determination of the appropriate level of financial burden incurred by individuals using them. However, defining essential medical service is difficult, likewise, among the various essential medical services, prioritizing the services to decide which medical service can be claimed first. Furthermore, setting an appropriate and fair level of financial burden for the service is also challenging. Therefore, to achieve coverage enhancement of health insurance, consistent principles and standards from a long-term perspective should be established legally and systematically based on democratic consensus. Such principles and standards reflecting prevailing social values should determine the overall direction of policy and play the role of mediating conflicting interests among stakeholders when making decisions for detailed policy. Under such principles and standards, National Health Insurance stakeholders, namely insurance policy holders, medical institutions, insurance carriers, and government, should engage in thorough discussions and consultations, and proceed through a reasonable and transparent decision-making process to determine major policies for coverage enhancement.
Moreover, when pursuing coverage enhancement, the equilibrium between insurance premium inflows and insurance benefit outflows should be maintained. To avoid imprudent expansion of coverage that ignores the realistic limitations of insurance financing, a professional evaluation process based on the principle of public health insurance should be implemented. In addition, insurance budgets should be managed based on objective and reasonable health care benefit standards, and measures should be taken to guarantee sustainability of coverage improvement and observe limitations set by the constitutional state, such as securing optimal medical charges so that the property right and occupational freedom of health care providers operating medical institutions are not infringed.
Based on the understanding of the health care benefit system and health care benefit standards that form the legal and systematic basis for National Health Insurance coverage enhancement, measures for such can be proposed as follows: (1) as improvement measure for expanding health care benefits and reducing co-payment, a Comprehensive Plan for National Health Insurance 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; (2) as for improvement measures to determine optimal medical charges, trust in medical expense negotiations should be established, the medical charges contracting system should more adequately guarantee freedom of contract, and adjustment and mediation for the decision of optimal medical charge should be provided when negotiations over medical expenses fail; (3) as for improvement measures for reasonable and fair evaluation of health care benefit cost, the evaluation system for such benefits should be restructured, objective and fair evaluation standards should be established, and the independence and professionalism of the Health Insurance Review and Assessment Service should be enhanced.
For complementary measures of the health care benefit system regarding the limitations of coverage improvement of the National Health Insurance, the following are examined: (1) restricted application and appropriate management of arbitrary non-benefit care arising from the health care benefit system’s structural problems, (2) reorganization of the medical expenses payment system to resolve problems of the current treatment-based payment system, and (3) role sharing of commercial health insurance to supplement medical security limitations provided under the National Health Insurance.

목차 (Table of Contents)

• 제1장 서론 1
• 제1절 연구의 목적 1
• 제2절 연구의 방법 및 범위 5
• 제2장 사회국가원리와 국민건강보험의 보장성 강화에 대한 요청 8
• 제1절 사회국가원리와 의료보장 8
• Ⅰ. 사회국가원리의 헌법적 의의 8
• 1. 사회국가의 개념과 그 이념으로서 ‘사회적 정의’ 8
• 2. 사회국가원리의 규범적 성격과 실현구조 10
• 3. 사회국가원리의 한계 12
• Ⅱ. 보건권과 사회보장제도 14
• 1. 보건권의 개념과 효력 14
• 2. 의료서비스의 특성으로서 ‘공공성’ 16
• 3. 사회보장제도를 통한 보건권의 실현 17
• Ⅲ. 의료보장의 의미와 공적 의료보장의 중요성 19
• 1. 의료보장의 개념과 특성 19
• 2. 의료보장의 유형 21
• 3. 공적 의료보장의 중요성과 국가개입의 한계 23
• 제2절 국민건강보험의 의의와 역사적 발전 25
• Ⅰ. 국민건강보험의 의의와 특성 25
• 1. 국민건강보험의 의의와 기능 25
• 2. 사회보험제도로서 국민건강보험의 특성 26
• 3. 현행 국민건강보험의 특성 28
• Ⅱ. 국민건강보험의 실현구조 30
• 1. 국민건강보험의 운영주체 30
• 2. 가입자의 보험료 납부를 통한 재원조달 31
• 3. 질병·부상에 대한 보험급여의 제공 33
• Ⅲ. 국민건강보험의 역사적 발전과 현대적 과제 34
• 1. 공적 의료보험제도의 도입과 전 국민 확대 34
• 2. 단일 보험자체계의 확립 35
• 3. 국민건강보험의 위기요인과 새로운 과제 37
• 제3절 국민건강보험의 보장성 강화를 위한 정책적 노력 39
• Ⅰ. 국민건강보험의 보장성 강화 39
• 1. ‘건강보험 보장성’의 개념과 헌법적 의의 39
• 2. ‘건강보험 보장성’의 평가지표 및 현황 40
• 3. ‘건강보험 보장성’ 강화의 방법 41
• Ⅱ. 국민건강보험의 보장성 강화를 위한 고려요소 43
• 1. 가입자의 건강한 삶을 위한 기본권 보장에 충실한 보장성 수준 43
• 2. 건강보험 재정의 한계 44
• 3. 요양기관 당연지정제 하에서 의료인의 권리보호 45
• Ⅲ. 국민건강보험의 보장성 강화를 위한 정책적 노력과 한계 46
• 1. ‘건강보험 보장성’ 강화를 위한 역대 정책 46
• 2. 역대 ‘건강보험 보장성’ 강화 정책의 한계 48
• 3. 최근의 보장성 강화 정책 : ‘문재인 케어’ 49
• 제3장 건강보험 보장성 강화에서 요양급여제도의 비중과 문제상황 51
• 제1절 국민건강보험법상 요양급여제도의 의의와 내용 51
• Ⅰ. 국민건강보험이 제공하는 의료서비스로서 ‘요양급여’ 51
• 1. 요양급여의 의의 51
• 2. 요양급여의 범위 52
• 3. 요양급여의 대상과 내용 53
• Ⅱ. 요양급여에 대한 대가로서 ‘요양급여비용’ 56
• 1. 요양급여비용의 의의 56
• 2. 요양급여비용의 산정 57
• 3. 요양급여비용의 부담 59
• Ⅲ. 건강보험심사평가원의 ‘요양급여비용 심사’를 통한 요양급여 확정 60
• 1. 건강보험심사평가원의 기능과 역할 60
• 2. 요양급여비용 심사를 통한 요양급여 확정의 필요성 61
• 3. 요양급여비용 심사의 의미와 절차 62
• 제2절 요양급여제도에서 요양급여기준의 역할과 비중 64
• Ⅰ. 요양급여기준의 의의와 법적 성격 64
• 1. 요양급여기준의 의의 64
• 2. 요양급여기준의 법적 근거 65
• 3. 요양급여기준의 법적 성격 및 효력 67
• Ⅱ. 요양급여기준에 따른 건강보험 보장성 강화의 규범구조 68
• 1. 요양급여 확대와 본인부담금 조정의 규범구조 68
• 2. 건강보험 원리에 입각한 전문적 평가절차 70
• 3. 건강보험정책심의위원회의 심의·의결 및 보건복지부장관의 결정·고시 72
• Ⅲ. 요양급여기준이 건강보험 보장성 강화에서 갖는 의미 73
• 1. 건강보험 보장성 강화의 법적·제도적 기초 73
• 2. 건강보험 재정의 효율적 관리를 위한 기준 74
• 3. 의료인의 기본권 제한의 법적 근거와 한계 75
• 제3절 건강보험 보장성 강화에 따른 요양급여제도의 문제상황 77
• Ⅰ. 요양급여 확대와 본인부담금 조정의 문제상황 77
• 1. 보장성 강화 정책에 관한 일관된 원칙과 기준의 부재(不在) 77
• 2. 전문적 평가절차의 형해화 79
• 3. 건강보험정책심의위원회의 구조 및 운영상 문제점 81
• Ⅱ. 요양급여비용 산정에서 ‘적정수가’ 보장의 문제상황 83
• 1. ‘低수가’ 문제와 ‘적정수가’ 보장의 필요성 83
• 2. 수가계약제의 문제점 84
• 3. 수가협상 결렬에 대한 합리적 해결방안의 부재(不在) 87
• Ⅲ. 건강보험심사평가원의 요양급여비용 심사의 문제상황 88
• 1. 보험재정의 안정에 편향된 요양급여비용 심사 88
• 2. 의료현장과 괴리된 ‘심사기준’ 89
• 3. 건강보험심사평가원의 독립성과 전문성 확보의 과제 90
• 제4장 지속가능한 보장성 강화를 위한 요양급여제도의 발전방향 94
• 제1절 건강보험 보장성 강화의 원칙과 기준 94
• Ⅰ. 건강보험 보장성 강화의 당면과제 94
• 1. 보편적 의료보장의 실현 94
• 2. 경제적 부담 완화를 통한 의료접근성 향상과 ‘재난적 의료비’ 해소 95
• 3. ‘필수의료’ 중심의 보장성 강화 96
• Ⅱ. 건강보험 보장성 강화를 위한 민주적 의사결정구조의 확립 97
• 1. 건강보험 보장성 강화를 위한 입법자의 역할 97
• 2. 건강보험 이해관계자의 참여를 통한 민주적 의사결정의 필요성 99
• 3. 건강보험의 특성을 고려한 전문적 평가절차의 중요성 100
• Ⅲ. 건강보험 보장성 강화의 법치국가적 기준과 한계 101
• 1. 급여우선순위 결정의 법적 원칙과 기준 101
• 2. 객관적이고 합리적인 요양급여기준을 통한 보험재정의 관리 102
• 3. 요양기관을 운영하는 의료인의 재산권과 직업의 자유 보장 103
• 제2절 건강보험 보장성 강화를 위한 요양급여제도의 개선방안 105
• Ⅰ. 요양급여 확대와 본인부담금 조정의 개선방안 105
• 1. 건강보험 보장성 강화의 원칙과 기준을 제시하는 ‘종합계획’ 수립 106
• 2. 전문적 평가절차의 실질화 107
• 3. 건강보험정책심의위원회의 민주적 운영 109
• Ⅱ. ‘적정수가’ 결정을 위한 수가계약제의 개선방안 110
• 1. 수가협상을 위한 신뢰기반의 형성 111
• 2. 수가계약제의 개선방안 112
• 3. 조정과 중재를 통한 ‘적정수가’의 결정 113
• Ⅲ. 합리적이고 공정한 요양급여비용 심사를 위한 개선방안 114
• 1. 요양급여비용 심사체계의 개편 필요성 114
• 2. 객관적이고 공정한 ‘심사기준’의 설정을 위한 개선방안 115
• 3. 건강보험심사평가원의 독립성과 전문성 강화 116
• 제3절 건강보험 보장성 강화의 한계와 요양급여제도의 보완방안 117
• Ⅰ. ‘임의비급여’의 제한적 허용과 적정한 관리 117
• 1. ‘임의비급여’의 의의 및 발생원인 117
• 2. ‘임의비급여’에 대한 규제 118
• 3. ‘임의비급여’의 적정한 관리방안 120
• Ⅱ. 진료비 지불제도의 개편 122
• 1. 행위별 수가제의 문제점과 한계 122
• 2. 새로운 진료비 지불제도의 도입 필요성 123
• 3. 행위별 수가제의 보완을 통한 진료비 지불제도의 개선방안 123
• Ⅲ. 민간의료보험에 의한 보완과 합리적 역할분담 125
• 1. 국민건강보험이 제공하는 의료보장의 한계 125
• 2. 민간의료보험의 기능과 역할 126
• 3. 국민건강보험과 민간의료보험의 합리적 역할분담 모델 127
• 제5장 결론 130
• 참고문헌 137