Health Policy and Management (보건행정학회지)

Korean Academy of Health Policy and Management (한국보건행정학회)
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An Implementation Analysis of the National Health Insurance Coverage Expansion Policy in Korea: Application of the Winter Implementation Model

건강보험 보장성 확대정책의 집행분석: Winter의 정책집행모형의 적용

  • You, Sooyeon (Department of Public Administration, Ewha Womans University Graduate School) ;
  • Kang, Minah (Department of Public Administration, Ewha Womans University College of Social Sciences) ;
  • Kwon, Soonman (Graduate School of Public Health, Seoul National University)
  • 유수연 (이화여자대학교 대학원 행정학과) ;
  • 강민아 (이화여자대학교 사회과학대학 행정학과) ;
  • 권순만 (서울대학교 보건대학원)
  • Received : 2014.04.30
  • Accepted : 2014.07.01
  • Published : 2014.09.30
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Abstract

Background: Most studies on the national health insurance benefit expansion policy have focused on policy tools or decision-making 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 objectives of this study is to understand the implementation process of the benefit coverage expansion policy. Unlike other implementation 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 committee, 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. Patients, 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 incorporate its influence on the implementation phase.

Keywords

References

  1. Huh SI. Policy issues on the limited coverage of the national health insurance. Health Welfare Forum 2008;140:22-38.
  2. Huh SI. Evaluation of benefit extension strategies of the Korea National Health Insurance. Health Policy Manag 2009;19(3):142-165. https://doi.org/10.4332/KJHPA.2009.19.3.142
  3. Choi JK. The problem and the solution of NHI benefit package: focus on arbitrary uninsured benefits. Healthc Policy Forum 2008;6(4):91-97.
  4. Choi KC, Lee HY. Evaluation of NHI benefits policy (2005-2007) and review for subjects of expansion. Health Insurance Policy 2010;9(2):66-79.
  5. Huh SI, Shin HS, Kang MA, Kim TI, Kim CB. Plan for securing optimum level of NHI benefit. Seoul: Korea Institute for Health and Social Affairs; 2007.
  6. Kwon SM, Oh JH, Kang MA. The principle of NHI benefit priority-setting and application plan. Seoul: National Health Insurance Service; 2010.
  7. Organization for Economic Cooperation and Development. OECD health data 2009, 2010, 2011, 2012, 2013 [Internet]. Paris: Organization for Economic Cooperation and Development [cited 2014 Apr 29]. Available from: http://www.oecd.org/els/health/data.
  8. Pressman JL, Wildavsky AB. Implementation: how great expectations in Washington are dashed in Oakland or why it's amazing that federal programs work at all. 2nd ed. Berkeley: University of California Press; 1979.
  9. Van Meter DS, van Horn CE. The policy implementation process a conceptual framework. Adm Soc 1975;6(4):445-488. https://doi.org/10.1177/009539977500600404
  10. Hargrove, Erwin C. The missing link: the study of the implementation of social policy. Washington (DC): Urban Institute; 1975.
  11. DeLeon P. The missing link revisited: contemporary implementation research. Rev Policy Res 1999;16(3-4):311-338. https://doi.org/10.1111/j.1541-1338.1999.tb00887.x
  12. Choi JW. A critical review on the theoretical framework of policy implementation study. Korean Assoc Policy Stud 1998;7(1):173-206.
  13. Jeong JK, Choi JW, Lee S, Jeong JK. The principle of policy studies. Seoul: Daemyoung; 2008.
  14. Noh HJ. The principle of policy studies. Seoul: Parkyoungsa; 2009.
  15. Winter S. Integrating implementation research. In: Palumbo DJ, Calista DJ, editors. Implementation and the policy process: opening up the black box. New York: Greenwood Press; 1990.
  16. Sabatier PA. Top-down and bottom-up approaches to implementation research: a critical analysis and suggested synthesis. J Public Policy 1986; 6(1):21-48. https://doi.org/10.1017/S0143814X00003846
  17. Winter S. How policy-making affects implementation: the decentralization of the Danish disablement pension administration. Scan Polit Stud 1986;9(4):361-385. https://doi.org/10.1111/j.1467-9477.1986.tb00355.x
  18. Winer S. Explaining street-level bureaucratic behavior. Paper presented at: The XIII Research Conference of the Nordic Political Science Association; 2002 Aug 15-17; Aalborg, Denmark.
  19. Winer S. Political control, street-level bureaucrats and information asymmetry in regulatory and social policies. Paper presented at: The Annual Research Meeting of the Association for Public Policy Analysis and Management; 2003 Nov 6-8; Washington (DC), USA.
  20. Han SE. A study on the linkage between policy-making and implementation: focusing on the case study of information policy [dissertation]. Seoul: Seoul National University; 1998.
  21. Calista DJ. (1986). Linking policy intention and policy implementation the role of the organization in the integration of human services. Admin Soc 1986;18(2):263-286. https://doi.org/10.1177/009539978601800206
  22. Lindblom CE. (1959). The science of "muddling through". Public Admin Rev 1959;19(2):79-88. https://doi.org/10.2307/973677
  23. Sabatier P, Mazmanian D. The implementation of public policy: a framework of analysis. Policy Stud J 1980;8(4):538-560. https://doi.org/10.1111/j.1541-0072.1980.tb01266.x
  24. Hoppe R, van de Graaf H, van Dijk A. Implementation research and policy design: problem tractability, policy theory, and feasibility testing. Int Rev Admin Sci 1987;53(4):581-604. https://doi.org/10.1177/002085238705300407
  25. Kingdon JW. Agendas, alternatives, and public policies. Boston: Little, Brown; 1984.
  26. Williams W, Elmore RF. Social program implementation. New York: Academic Press; 1976.
  27. Palumbo DJ, Weiss CH, Chelimsky E, Patton MQ, Browne A, Wildavsky AB, et al. The politics of program evaluation. Newbury Park: Sage; 1987.
  28. Bardach E. The implementation game: what happens after a bill becomes a law. Cambridge (MA): MIT Press; 1977.
  29. Thompson FJ. Health policy and the bureaucracy: politics and implementation. Cambridge (MA): MIT Press; 1981.
  30. Lipsky M. Street-level bureaucracy: dilemmas of the individual in public services. New York: Russell Sage Foundation; 1980.
  31. Yang NJ. A policy implementation analysis on the care voucher for the aged: focusing on choice and competition. Korean J Soc Welf 2009;61(3): 77-101. https://doi.org/10.20970/kasw.2009.61.3.004
  32. Elmore RF. Backward mapping: implementation research and policy decisions. Polit Sci Q 1979;94(4):601-616. https://doi.org/10.2307/2149628
  33. Elmore RF. Reform and retrenchment: the politics of California school finance reform. Rand Educational Policy Study. Cambridge (MA): Ballinger; 1982.
  34. Strauss AL, Corbin JM. Basics of qualitative research: techniques and procedures for developing grounded theory. 2nd ed. Thousand Oaks (CA): Sage Publication; 1998.
  35. Miles MB, Huberman AM. Qualitative data analysis. 2nd ed. Thousand Oaks (CA): Sage Publication; 1994.
  36. Choi HK. An analysis on the process of setting fees for medical and pharmaceutical services in the national health insurance and the role of the government in the process. Korean Public Admin Rev 2004;38(2):127-147.
  37. Bae KH, Ha JE, Jin JH. Feedback on private enterprise insurance from focus group interviews and the proportion of uninsured benefits. J Korean Acad Oral Health 2010;34(2):291-301.
  38. Shon CW, Kwon SM, You MS. Policy elites' perception of health policy governance: findings from in-depth interviews of Korean New Diagnosis Related Group payment. Health Policy Manag 2013;23(4):326-343. DOI: http://dx.doi.org/10.4332/kjhpa.2013.23.4.326
  39. Brodkin EZ. Policy work: street-level organizations under new managerialism. J Public Admin Res Theory 2011;21(suppl 2):i253-i277. DOI: http://dx.doi.org/10.1093/jopart/muq093
  40. Gofen A. Mind the gap: dimensions and influence of street-level divergence. J Public Admin Res Theory 2014;24(2):473-493. DOI: http://dx.doi.org/10.1093/jopart/mut037
  41. May PJ, Winter SC. Politicians, managers, and street-level bureaucrats: influences on policy implementation. J Public Admin Res Theory 2009; 19(3): 453-476. DOI: http://dx.doi.org/10.1093/jopart/mum030
  42. Meyers MK, Vorsanger S. Street-level bureaucrats and the implementation of public policy. In: Peters BG, Pierre J, editors. Handbook of public administration. Thousand Oaks (CA): Sage Publications; 2003. pp. 245-255.
  43. Park SB, Lee JY. The lecture on policy studies. Seoul: Parkyoungsa; 2005.
  44. Levin M, Fennan B. The political hand: policy implementation and youth employment programs. J Policy Anal Manag 1986;5(2):311-325. https://doi.org/10.2307/3323547