Japanese multiple payer vs. Korean single-payer health insurance Jeong, HS Professor Yonsei University

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1 <Tri-country conference, Japan Health Economic Association The 6th Annual Meetings, Hosei University, 18 Sept 2011 > Japanese multiple payer vs. Korean single-payer health insurance Jeong, HS Professor Yonsei University

2 Towards Universal Coverage

3 Transition to Universal Coverage Germany Belgium Israel Austria Luxemburg Japan Korea 12 yr 34yr 72 yr 84 yr 79yr 118 yr 127 yr Self-employed or Non-employed Employed Korea: Japan: (1927) (1961) Medical Aid Program

4 Historical development (towards universal coverage) Prior to the introduction of public health insurance scheme Introduction and development of worksite health insurance Introduction and development of locality health insurance Japan 1911: Workman s Compensation scheme started 1922: Health Insurance Act written into law 1927: Employment Health Insurance (EHI) started for blue-collar employees 1934: EHI expanded to businesses with 5 employees or more 1937: EHI expanded to white- collar employees 1941: Insurance for government employees started 1939: EHI for white-collar employees established independently 1941: EHI applied to employees dependents 1942 EHI incorporated both blue- and white-collar employees 1938: National Health Insurance (NHI) Act passed (NHI programs by municipalities) 1958: New NHI Act passed 1961: NHI programs applied to all municipalities, and thereby implementing Health-insurance-for-all Korea 1963: Health Insurance Act written into law 1964: Workman s Compensation scheme started 1977: Compulsory health insurance started for businesses with 500 employees or more 1979: Insurance for government employees (KMIC) organized, and Compulsory health insurance expanded to businesses with 16 employees or more 1981: Compulsory health insurance expanded to businesses with 100 employees or more 1983: Compulsory health insurance expanded to businesses with 16 employees or more 1988: Compulsory health insurance expanded to businesses with 5 employees or more 1988: Compulsory health insurance expanded to cover farming and fishing communities 1989: Compulsory health insurance expanded to cover urban area, and thereby implementing healthinsurance-for-all Jeong, HS and Niki, R, (forthcoming), Divergence in the development of public health insurance in Japan and Korea: multiple payers versus single payer, International Social Security Review.

5 Similar Health Insurance System (before 2000) Japan Korea Source: Jeong, HS et.al. (2001), An assessment of the performance of the Japanese health care system, OECD, Paris.

6 Towards Unification / Integration

7 Integration of insurers in Korea About 370 insurers including 142 health insurance Societies for employees and 227 Societies for the self-employed were integrated into one organization in July Demarcation between worksite and locality insurance accounts under the NHIC was removed in 2003.

8 Transition to Single-payer NHI in Korea Integration reform in 2000

9 Types of integration in Japan Types Harmonization in contributions and benefits Japanese terminology Ichigenka ( Harmonization ) Contents - To remove differences in contributions and benefits without changing organization itself Examples - Measure to rectify the imbalances of contributions and gaps of benefits since 1960s - Co-payment rates uniformly pegged at 30% in 2003 Organizational integration Kouikika ( Enlargement ) Ipponka ( Integration in a narrow sense) - To expand the size of individual insurers and curtail the number of insurers - To keep worksite insurers and locality insurers separate - To integrate worksite insurer and locality insurer under the same insurer - Health insurance for whitecollar employees incorporated into the employee health insurance (EHI) in General Headquarters idea in Ikeda administration idea in Memorandum item 5 in late 1980s - Democratic Party of Japan (LPJ) public pledge in Koizumi government s Basic guideline in 2003 to expand insurers prefecture by prefecture Jeong, HS and Niki, R, (forthcoming), Divergence in the development of public health insurance in Japan and Korea: multiple payers versus single payer, International Social Security Review.

10 Organizational change in both countries 1968, 1973, 1984 and 2003: Co-payment rates adjusted and finally pegged uniformly at 30% in : Health Service System for the Elderly started 2008: Medical Care Scheme for the Senior Elderly started

11 Idealtypus (ideal type) vs Realtypus (real type) Characteristics and structure of primary financing sources Public-Private Mix Number of organizations Idealtypus (ideal type) of national health systems Realtypus (real type) of national health systems NHS (UK etc) Single payer Public single payer NHI (Korea since 2000) Public NHS SHI (Canada) (France) Public multiple payers SHI (Germany, Japan) (Korea before 2000) Multiple payers Mexico Private Private payers U.S.A Jeong, HS and Niki, R, (forthcoming), Divergence in the development of public health insurance in Japan and Korea: multiple payers versus single payer, International Social Security Review.

12 Discussions and Concluding observations

13 Axis of Ideology/ conviction Power resources analysis for Korean case Strong stakeholder Week stakeholder Move caused by change In political environments FDLU: Federation of Democratic Labor Unions KFLU: Korea Federation of Labor Unions Worksite Insurance (KFLU) Civil societies Ministry of Health Business Management Medical providers Proponents Locality Insurance (FDLU) Axis of interest Ministry of Health Opponents Jeong, HS, et.al. (2010), Chapter 2.Making health system reform happen: what can other countries learn from Korea?, Making Reform Happen: Lessons from Korea since the 1987 Democratization, KDI.

14 Axis of Ideology/ conviction Power resources analysis for Japanese case Strong stakeholder Proponents Week stakeholder Business Management Worksite Insurance (SMHI/GMHI) Medical providers Locality Insurance (NHI) Axis of interest Ministry of Health Opponents

15 Analysis into policy environments Factors for policy diffusion and policy divergence (policy diffusion) Majority of the bureaucrats who joined the government service prior to 1980s were used to referring to laws and institutions introduced in the Japanese language. (policy divergence) Differences in a) tradition of local autonomy, b) political leadership, c) length of time of health insurance systems Economic crisis Financial crisis that hit Korea at the end of 1997 Economic depression in Japan since the 1990s down to the present time Democratization and social welfare (Korea) Integration was considered as an expansion of social welfare. Shifts in political environment, including the democratization and the advent of major bottom-up social forces in favor of the reform, opened a window of opportunity for the reform. (Japan) Though parliamentary democracy was firmly established in Japan, the perception that social welfare was granted preferentially by bureaucratic elites was deeply entrenched with political monopoly being held by the Liberal Democratic Party (LPD) for a long time. It has been difficult to turn around deep-rooted fundamentals of health insurance system shaped by such elite bureaucrats.

16 Observations First, neither the corporative approach (multiple-insurer system) nor the integrative approach (single-payer system) alone turns out right at all times. In the early days when health insurance was introduced in both Japan and Korea it was not administratively plausible to implement the expansion of the program in an integrative approach. But with the framework of health insurance falling into place and the data processing infrastructure being built, environments have already been changed. A larger insurer is now capable of managing a largescaled population. Second, the approach of uniformly allotting insurance contributions to the employed and self-employers is not a necessary condition in putting the two groups under one insurer. For integration, it is possible to merge financial and administrative controls without unifying contribution methods. Currently in Korea, professional expertise for strategic purchases of health care is rapidly gathering momentum under the single-payer system enrolling the entire nation.

17 Health System Performance Total system Performance (2) Managerial efficiency (2) 1 Risk pooling performance 1 S1 S2 Population size

18 Lessons learned In the case of Japan, there are good reasons for operating health insurance organizations region by region, but it seems that fragmented insurers numbering almost 3,600 needs to be reorganized into fewer but larger organizations. In the case of developing countries, while starting with a single-payer system would best serve them that are seeking universal coverage, launching such a system all at once would certainly cause big challenges. Universal coverage is often achieved through a variety of schemes. From a strategic perspective, it would be a possible alternative to make it an official goal from the outset to ultimately switch over to a single-payer system while starting insurance with the feasible groups. This is what the trial and error Korea had experienced for over 20 years in an ideological war of attrition has to teach.

19 Thank You

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