건강보험 보장성 확대정책의 집행분석: Winter의 정책집행모형의 적용

Abstract

Background: Most studies on the national health insurance benefit expansion policy have focused on policy tools or decision-mak-ing process. Hence there was not enough understanding on how policies are actually implemented within the specific policy context in Korea which has a national mandatory health insurance system with a dominant proportion of private providers. The main objec-tives of this study is to understand the implementation process of the benefit coverage expansion policy. Unlike other implementa-tion studies, we tried to examine both the process of implementation and decision making and how they interact with each other.Methods: Interviews were conducted with the ex-members of the Health Insurance Policy Review Committee. Medical doctors who implement the policy at the ‘street-level’ were also interviewed. To figure out major variables and the degree of their influences, the data were analyzed with Winter’s Policy Implementation Model which integrates the decision making and implementation phases.Results: As predicted by the Winter model, problems in the decision making phase, such as conflicts among the members of com-mittee, lack of applicable causal theories application of highly symbolic activities, and limited attention of citizen to the issue are key variables that cause the ‘implementation failure.’ In the implementation phase, hospitals’ own financial interests and practitioners’ dependence on the hospitals’ guidance were barriers to meeting the policy goals of providing a better coverage for patients. Pa-tients, the target group, tend to prefer physicians who prescribe more treatment and medicine. To note, ‘fixers’ who can link and fill the gap between the decision-makers and implementers were not present.Conclusion: For achieving the policy goal of providing a better and more coverage to patients, the critical roles of medical providers as street-level implementers should be noted. Also decision making process of benefit package expansion policy should incorpo-rate its influence on the implementation phase.Keywords: Implementation; National Health Insurance; Benefit expansion policy; Winter’s Policy Implementation Model; Fixer; Street-level bureaucrat