The National Health Insurance system, a social safety net to ease the public's medical expenses, was introduced in 1977. The scope of coverage was gradually expanded to complete universal health insurance in 1989. Starting with hospital room fees, the coverage continued to widen to include MRI and ultrasound tests. But as coverage expanded, the fiscal burden ballooned, and fairness disputes over reimbursement criteria have persisted. In this context, President Lee Jae-myung recently reignited debate by directing a review to expand coverage for hair loss treatment, saying "hair loss is a matter of survival." We examine the major issues surrounding the National Health Insurance system and the pros and cons of expanding coverage. [Editor's note]
#A man in his 60s surnamed Lee, who had been battling liver cancer, was hospitalized at a general hospital in North Gyeongsang Province two years ago as his condition worsened. Although he did not want life-prolonging treatment, he underwent various imaging tests at the hospital's recommendation. He died three days later. The bereaved family said, "At the time, the patient was in such pain that even lifting his arm during the imaging process was difficult," and noted, "We are left wondering whether the tests were really necessary when death was imminent."
Fiscal pressure on the National Health Insurance is becoming a reality. Health experts say the financial burden is inevitable due to low birthrates and an aging population, but spending has been ramped up immediately.
According to a social insurance report published by the National Assembly Budget Office in Aug. 2025, the point at which health insurance reserves are depleted has been moved up to 2028, two years earlier than the initial projection of 2030. The budget office said, "This reflects $20 trillion won in medical reform investments from 2024 to 2028 and the emergency care system into which 200 billion won per month will be invested through 2025," adding, "With aging and expanded coverage, an increase in health insurance expenditure is inevitable."
◇ After "Moon Jae-in Care," MRIs up 13-fold… "It's cheap, so let's take one"
Experts point to the so-called coverage expansion policy known as "Moon Jae-in Care" as the key cause of fiscal deterioration. Implemented starting in 2018, the policy brought a large number of imaging tests such as CT, MRI, and ultrasound, as well as two- to three-person rooms, into National Health Insurance benefits.
As a result, patients' perceived medical costs fell sharply. For brain and cerebrovascular MRIs, patients had to pay 500,000–700,000 won before coverage, but after reimbursement the out-of-pocket cost dropped to about 180,000 won.
But medical use surged. On the ground, there are concerns that testing practices spread in cases without strong medical necessity, along the lines of "It's cheap anyway, so let's take one." In fact, in 2019, the year after brain and cerebrovascular MRI coverage was expanded, the number of MRIs performed for headaches and dizziness reached 609,449, 13 times the 43,928 in 2017. Of these, 45% were for simple headaches and dizziness, cases in which MRIs are not clinically necessary.
A surge in imaging tests for foreign patients was also flagged as a problem. At the National Assembly's 2023 audit, lawmakers took issue with the fact that after Moon Jae-in Care, imaging tests for foreigners increased far more than for citizens.
The government belatedly hit the brakes. Starting in April 2020, it tightened the standards to approve MRI reimbursement only when seven medical red flags, such as cancer or "thunderclap headache," are present. An official at the Ministry of Health and Welfare acknowledged, "Rapid reimbursement of high-cost imaging led to some overuse of unnecessary tests."
Over five years under the Moon Jae-in administration, 2.64 trillion won in health insurance funds were spent to expand coverage. Of that, 142.72 billion won was spent from 2018 to 2022 to reimburse MRIs.
Choi Sun-hyung, president of the Korean Society of Radiology Practitioners, said, "After expanding MRI and ultrasound reimbursement, the 'disease recognition rate,' which measures early detection, clearly rose," but added, "It was a problem that coverage broadened quickly without standards and utilization management to determine what tests are truly needed." Choi said, "Because the policy focused on lowering patient burdens, it fell short of ensuring effectiveness commensurate with the health insurance funds invested."
The problem of overtreatment is particularly pronounced among older adults, experts say. Choi said, "For older patients, out-of-pocket costs are only a few thousand won no matter what test is done, so the choice to 'take one more' is inevitably repeated," adding, "It is hard to deny that expanded coverage structurally increased testing frequency."
◇ CT, MRI, ultrasound cost 5 trillion won a year… "Testing also surges a month before death"
Once tests are brought into the benefit basket, it is hard to cut expenditure. An analysis by ChosunBiz of Health Insurance Review & Assessment Service data shows that annual reimbursement claims for major imaging tests such as CT, MRI, and ultrasound rose 2.6 times, from the 2 trillion won range in 2017 to 5.2486 trillion won in 2024.
The number of ultrasound patients jumped from 1.76 million to 11.23 million over seven years, and both patient counts and claims for MRIs and CTs also rose sharply. In 2024, claims for ultrasound and MRI increased 364% and 196%, respectively, from 2017, to 2.3315 trillion won and 1.769 trillion won.
The increase was especially notable among those 80 and older. The number of CT patients aged 80 and above rose from 390,000 in 2017 to 770,000 in 2024. The number of MRI patients aged 80 and above was 280,000 in 2024, up 170,000 from 2017. Ultrasound patients increased from 70,000 in 2017 to 560,000 last year, an increase of 490,000.
Imaging use also increased among patients near the end of life. According to an analysis by the National Health Insurance Service of benefit use in the year before death for 169,943 deceased recipients of the long-term care insurance for seniors in 2023, 31.7% (53,823 people) underwent a CT in the last month of life, more than double the 14.6% in 2014.
Long-term care insurance is a social insurance system that supports long-term care services, such as in-home care visits and facility admission, for people aged 65 or older and patients with certain conditions such as dementia and cerebrovascular disease who struggle with daily living. For those insured through their workplace, the premium is included in the health insurance contribution and is split equally by the company and the worker, while regional subscribers pay the full amount themselves.
Lee Sang-il, a professor at Jeju National University, said, "There is a clear tendency for medical expenditure to concentrate among patients near the end of life," adding, "Not a few cases involve choosing tests with limited medical benefits."
◇ "Moon Care" backlash makes "repairs" inevitable... burden of workplace health insurance premiums up 50%
The fiscal burden from demographic changes and expanded coverage ultimately falls on the public. Experts also say premium hikes are inevitable to sustain the system.
In fact, the health insurance premiums paid by the public have steadily risen. Both income, which is the basis for calculating premiums, and the health insurance contribution rate have increased, so the actual amount subscribers pay keeps going up.
For workplace subscribers, the premium is calculated by multiplying monthly wages by the contribution rate. Premiums are based on salary and split between the company (corporations) and the worker. The workplace contribution rate, which was 5.89% in 2013, entered the 6% range in 2015, reached 7.09% from 2023 to 2025, and was raised to 7.19% next year. The average monthly health insurance premium for workplace subscribers rose from about 107,000 won in 2017 to about 145,000 won in 2022, up about 35% in the six years since Moon Jae-in Care began. The upward trend has continued, and in 2026 it is expected to be around 160,000 won, with the increase rate approaching 50% compared to 2017.
The previous administration's coverage expansion policy has boomeranged to threaten the sustainability of health insurance. As a result, "repairs" to plug leaks are ongoing. The Lee Jae-myung administration has moved to adjust health insurance fees for the surging imaging tests.
The Ministry of Health and Welfare said on the 23rd of last month that it held the 24th Health Insurance Policy Deliberation Committee and will push for a rational overhaul of the fee system. During the Moon Jae-in administration, more than 3,800 non-covered items such as ultrasound, CT, and MRI were converted to covered benefits, deepening revenue imbalances that it now seeks to fix. The medical community broadly views Moon Jae-in Care as having focused only on lowering the public's medical burdens, thereby exacerbating the essential care crisis.
According to the 2023 fiscal year medical cost analysis released by the Health Insurance Policy Deliberation Committee's medical cost analysis subcommittee, at tertiary hospitals the revenue-to-expense ratio for imaging diagnostics (such as CT and MRI) was 169%, and for radiation therapy it was a very high 274%. By contrast, the revenue-to-expense ratio for basic care fees (consultations and inpatient care), which require significant clinician labor, did not even reach cost.
The Lee Jae-myung administration said it will lower fees in the overcompensated imaging sector and use the resources saved to address undercompensation in essential care areas such as basic care, severe and emergency care, pediatrics, and childbirth. Through the "Second Comprehensive Health Insurance Plan," it will continuously adjust relative value units based on medical cost analyses, though it has not yet presented a specific implementation schedule or phased timeline.
Experts advise cutting excessive medical expenditure and pushing to make health insurance more efficient by using resources effectively.
Hong Seok-cheol, head of the Health Finance Research Center at Seoul National University (economics professor), said, "There are projections that the contribution rate will reach 8% in 2030," adding, "Efficiency in health insurance expenditure is needed."
Oh Joo-hwan, a professor at Seoul National University College of Medicine, said, "Merely adjusting fees for overcompensated items like imaging tests will not solve the problem." Under the current fee-for-service system, the more tests and prescriptions there are, the greater the compensation; if fees for certain tests are cut, providers may be incentivized to increase other tests or prescriptions to make up revenue.
Oh said, "Unless compensation is also adjusted in clearly undervalued areas such as consultation and nursing fees, fee adjustments will struggle to drive behavior change on the ground."