미국 의료개혁의 정치경제학

최병호 ( Byong Ho Tchoe ) 한국보건경제정책학회(구 한국보건경제학회) 2011 보건경제와 정책연구 Vol.17 No.1

1912년 루스벨트가 대선공약으로 전국민건강보험을 주창한지 거의 백년만인 2010년 3월 25일 미국의 의료개혁법안이 의회를 통과하였다. 의료개혁은 항상 대선의 이슈로 등장하였고 이해집단들이 첨예하게 대립하는 정치경제적인 문제였다. 오바마 집권초기에는 외교문제와 경제침체, 금융위기 등 산적한 현안들이 많아 의료개혁에 집중할 정치적 자산(political capital)이 부족할 것으로 예상되었다. 그러나 오바마는 의료개혁을 국정과제의 제일순위에 두고 모든 역량을 투입하여 관철하였다. 그리고 상하원을 민주당이 장악한 정치구조도 개혁을 가능하게 하였다. 여건의 변화도 개혁을 뒷받침하였다. 민간보험료의 급상승으로 기업의 부담이 과중하게 되면서 클린턴정부 때에 개혁을 좌초시킨 민간보험업계는 협조로 선회하였다. 민간보험은 협조하는 대신에 공보험 도입을 저지하는 전략을 구사했고 성공했다. 제약회사 등 보건산업도 개혁을 지지하면서 실리를 얻어내는 방향으로 전략을 수정했다. 의사단체들과 시민단체들은 개혁에 대한 지지와 반대로 나뉘었으나, 대세는 지지쪽으로 기울었다. 의사들은 HMO 방식의 민간보험의 규제에 대해 서서히 반감이 깊어져 왔었다. 가장 큰 패배자는 공화당이었으나, 오바마 역시 공화당의 지지를 단 한표도 얻지 못해 정치적 리더십에 큰 상처를 입었다. 그리고 11월 중간선거에서 공화당이 하원을 장악함으로써 의료개혁의 미래는 불안해졌고, 향후 차기대선의 향방에 따라 10년에 걸쳐 추진되는 의료개혁의 갈 길도 험난해져 보인다. The US health care reform bill was legislated on March 25th, 2010, around 100 years since Theodore Roosebelt took the universal health care as a presidential promise in 1912. Health care reform had been always one of the most contentious issues in the presidential elections, and was deeply related to the interests of players of health care market. At first, it seemed impossible to achieve the health care reform, because the Obama administration was facing tough and urgent foreign policies, economic recession, and financial crisis, and therefore Obama would not have his political capital to pour into the health care reform. Obama set the health care reform on top priority and pushed ahead with his all political capability. Democrat-led House and Senate could make the reform possible. Economic and political environment was changed positively unlike that of Clinton administration. Employers could not bear the skyrocketing surge of private insurance cost. So private insurers promised to cooperate with the reform, and instead they asked the administration not to introduce public option. And health industry announced to support the reform and did their best for the protection and even more profits. Doctors associations and civic groups had been separated with pros and cons, and pros had become dominating cons as time went on. Especially doctors had a growing antipathy toward HMO-type insurers. The biggest loser was Republican, and also Obama could not get a single vote yes from the Republican and lost political leadership. Further, the November mid-term election provided the majority of House to the Republican, that will make the implementation of health care reform unstable, and the future of health care reform will get caught in adversity depending upon the results of coming presidential elections.

국민의료비의 적정수준에 관한 연구

최병호 ( Byong Ho Tchoe ) 한국보건경제정책학회(구 한국보건경제학회) 2006 보건경제와 정책연구 Vol.12 No.1

건강보험의 직장과 지역간 보험료 형평부담에 관한 고찰

최병호 ( Byong Ho Tchoe ),신현웅 ( Hyun Woong Shin ) 한국보건경제정책학회(구 한국보건경제학회) 2005 보건경제와 정책연구 Vol.11 No.1

건강보험제도의 경제적 후생손실에 관한 고찰

최병호 ( Byong Ho Tchoe ) 한국보건경제정책학회(구 한국보건경제학회) 2004 보건경제와 정책연구 Vol.10 No.1

의료보험(醫療保險) 급여범위(給與範圍)의 적정한계(適正限界)에 관한 고찰(考察)

최병호 ( Byong-ho Tchoe ) 한국보건사회연구원 1996 保健社會硏究 Vol.16 No.1

현재 醫療保險의 制限的인 給與範圍로 인해 진료시 患者負擔이 過重하여 社會保險으로서의 實效性에 대한 批判이 제기되고 있으며, 최근의 醫療保險改革 論議에서 급여범위의 확대방향이 활발하게 모색되고 있다. 본고는 이러한 給與擴大의 適正與否에 대한 妥當性을 고찰하려는 것이 목적으로써, 현재의 給與範圍와 非保險給與 및 本人負擔金에 대한 實態를 파악하고, 適正保險範圍와 本人負擔金에 대한 이론적, 실증적 연구로부터 우리에게 주는 示唆點을 도출하려 하였다. 保險給與의 適正性은 效率性(厚生增進, 道德的 危害), 衡平性(醫療接近度와 負擔의 衡平) 및 醫療의 質의 均衡에 의해 판단되어야 할 것이다. 이러한 관점에서 볼 때, 保險給與期間의 制限은 조속히 철폐되어야 하며, 非給與 중 檢査料와 食代, 특히 障碍人의 醫療用具를 보험급여화하고, 上級病室料差額과 指定診療料는 엄격한 規制를 통하여 最小限으로 운영되어야 할 것이다. 이에 따른 의료기관의 經營惡化에 대비하여 技術料 中心의 保險酬價의 引上이 병행되어야 할 것이며, 급여확대에 따른 過剩診療의 副作用은 醫療體系의 改善을 통해 흡수하여야 할 것이다. 또한 보험급여비 증가에 따른 保險料의 引上을 소득계층간에 適正하게 分擔할 수 있도록 保險料賦課體系, 조합간 財政共同事業, 國庫負擔金의 差等配分 等 支援體系가 뒷받침되어야 할 것이다. The benefits coverage of the Korean National Health Insurance is very restricted and so the out-of-pocket payment of patients is high. Therefore there are much criticism about health insurance program as a social insurance, and recent health care reform committees suggest expanding coverage of insurance or shrinking out-of-pocket payment. The objective of this paper is providing an answer to the question what is optimal benefits of health insurance, that is, how much the social health insurance should cover the financial burden from risks of health. In other words, the issue is regarding the optimal level of out-of-pocket payment of patients. The optinal coverage of insurance could be decided on the consideration of balancing among efficiency (welfare improvement, moral hazard), social equity(equitable access to health care and financial burden), and quality of health care. Suggestions are as follows. First, the limit of insurance period must be eliminated soon. Second, tests and diets have to be insured, especially appliances of the disabled must be insured. Third, user fees for upper-class sickroom and designated consultation fees shoud be regulated strongly. To make those suggestions workable, the insurance fees have to be increased against the hospitals` financing hardship, and so the subsequent burden of premium increment must be allocated through some risk adjustment mechanisms such as premium schedule adjustment, risk sharing between funds, and government subsidy.

사회보장제도의 재분배효과와 전망

최병호 ( Byong Ho Tchoe ),김태완 ( Tae Wan Kim ) 한국사회보장학회 2005 사회보장연구 Vol.21 No.3

소득불평등 개선을 위한 사회보장제도

최병호 ( Byong Ho Tchoe ),김태완 ( Tae Wan Kim ) 한국응용경제학회 2006 응용경제 Vol.8 No.2

國民年金의 厚生費用 歸着에 대한 一般均衡 시뮬레이션 分析

崔秉浩(Byong-Ho Tchoe) 한국재정학회(구 한국재정·공공경제학회) 1996 재정논집 Vol.10 No.-

There have been many discussions about the economic distortions of social security. This paper analyzes the Welfare incidence among income groups. The method used is an applied equilibrium model in the context of lifecycle theory where the consumer is devided into five groups according to the lifetime income level. The main contributions and findings of this paper are as follows. First, it is a new approach to measure the distributional effects of social security taxation with lifecycle applied general equilibrium model. Second, the existing social security progrem has a progressive incidence in terms of the lifetime distribution of welfare, but imposes an efficiency cost on the economy. Third, the incidience of social security should be examined in a lifecycle framework, and should include social security benefits as well as taxes, or the results will be significantly biased. The analyze in this paper focuses on steady states. It would also be of intrest to analyze the transitional paths of welfare changes among each general annually. and to introduce the actual or estimated demographic change into the model. These extensions would provide further inwight the effects of social security.

국민의료비 결정요인분석

최병호 ( Byong Ho Tchoe ),남상호 ( Sang Ho Nam ),신윤정 ( Yoon Jung Shin ) 한국보건행정학회 2004 보건행정학회지 Vol.14 No.2

This study estimates the determinants of national health expenditures of OECD countries using panel regression method. The data used are OECD Health Data(2003) covering 33 countries and from 1970 to 2001. This study shows several important different results compared to the previous studies. Further this study estimates the determinants of Korean case using data from 1977 to 2000, and compare with the results of OECD panel. The main findings are as follows. The income elasticity of health expenditures is estimated below 1.0, but is shown above 1.0 when the different health systems of each country are controlled. The women`s labor participation influences strongly positive effect on the health expenditures. The diffusion of new technologies is positively related with the increasing expense. The increasing government expenditures have a tendency not to contain health expenses, but to increase expenses. The expansion of public health insurance holders is containing the expenses, and the increasing number of doctors is pushing expenditures. This implies the health expenditures are influenced more by the induced demand of providers rather than the moral hazard of patients. However, the above result is opposite in Korean case. The existence of primary care doctors affects slightly up warding rather than containing expenditures. Finally the determinants are seriously depending upon which factors are included in the model and which statistical model is chosen. Therefore it must be cautious to interpret the results of statistical model.

의료비의 부담구조 분석과 재편방안 고찰

최병호 ( Byong Ho Tchoe ),신현웅 ( Hyun Woong Shin ) 한국보건경제정책학회(구 한국보건경제학회) 2001 보건경제와 정책연구 Vol.7 No.1

This study discusses the enhancement of risk pooling, the efficient utilization of resources, and the improvement of equity of medical cost-bearing through the restructuring of medical costs. There are criticism on the current medical insurance; an weak protection against major risks, inefficient resource allocation such as the overly induced demand by medical providers, inappropriate claims or fraud, moral hazard of the patients` over-utilization on the minor risks. This paper suggests the following reform proposals. The reimbursement scheme should be reenforced against high copayment due to catastrophic care, while the cost of minor risks should be born by patients` burden by the introduction of "deductible" or medical saving account(MSA). This will enhance the efficiency(or reduce the welfare cost) through transforming the medical resources from the minor risks to the major risks. And the pooling of major risks will raise the social equity through the protection of households` bankrupt. This study proposed several measures and shows the results of simulation.