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Indonesia is a country which is still facing serious issues on health insurance. The health cost is still high and its service is not yet well-distributed in this country. Ironically, the state's contribution, as an institution which has the role to support prosperity of its citizens, is still far from ideal. The country may use its laws and authority to provide the National Health Insurance (Jaminan Kesehatan Nasional/JKN) for all citizens of Indonesia. One role of a country is to protect the rights and the health needs of its citizens as mandated in the Indonesian Constitution. By analyzing the National Health Insurance system of Indonesia, it may make us realize that in reality, hundreds of million citizens are in need. In line with the Mandate of the Constitution and the Human Rights Declaration, thus the Constitution Number 36 year 2009 on Health (which will be abbreviated UUK/Undang-Undang Kesehatan) states that every person has the right to receive health services. Because of that, every individual, family, and community have the right to receive protection of their health, and the state has the responsibility to make sure that the citizen's rights for living healthily are achieved, including for the poor and the needy. The National Health Insurance should also give the chance for groups of people under the poverty line to have a dignified standard of life, so that poverty is not inherited from one generation to the next.
Abstract
Indonesia is a country which is still facing serious issues on health insurance. The health cost is still high and its service is not yet well-distributed in this country. Ironically, the state's contribution, as an institution which has the role to support prosperity of its citizens, is still far from ideal.
The country may use its laws and authority to provide the National Health Insurance (Jaminan Kesehatan Nasional/JKN) for all citizens of Indonesia. One role of a country is to protect the rights and the health needs of its citizens as mandated in the Indonesian Constitution. By analyzing the National Health Insurance system of Indonesia, it may make us realize that in reality, hundreds of million citizens are in need.
In line with the Mandate of the Constitution and the Human Rights Declaration, thus the Constitution Number 36 year 2009 on Health (which will be abbreviated UUK/Undang-Undang Kesehatan) states that every person has the right to receive health services. Because of that, every individual, family, and community have the right to receive protection of their health, and the state has the responsibility to make sure that the citizen's rights for living healthily are achieved, including for the poor and the needy. The National Health Insurance should also give the chance for groups of people under the poverty line to have a dignified standard of life, so that poverty is not inherited from one generation to the next.
Keywords: insurance, health, national, ideal.
1.Background
The establishment of the social insurance, namely the National Health Insurance or JKN for every citizen as mandated in the Constitution Article 28H Paragraph (3) on social insurance and Article 34 Paragraph (2) on the Republic of Indonesia's 1945 Constitution states that, "the State develops a social insurance system for all citizens and it empowers the weak and the poor according to the human dignity" (Muhtaj, 2008, p. 152).
The National Health Insurance of Indonesia is a part of the national social welfare system in this country. The execution of Indonesia's JKN is a social insurance system which is full of issues, such as the cases where patients are rejected, the JKN budget which is much lower than the actual health fees, JKN sanctions and fines, and other problems which may disturb the smoothness in applying this health insurance. The condition where there are many issues regarding the JKN is a bitter reality.
The Indonesian National Social Insurance System, especially the National Health Insurance is a concept which is normatively the same as the social and the health insurances which are applied in other countries. The social insurance in this case are health insurances which are established by the state to give social protection to its citizens. The state establishes it with two concepts: the former is a full protection paid by the state, and the latter is a concept of social insurance which is compulsory. The latter requires fee payment from the citizens and is supported by the state.
The Constitution's mandate is the foundation of why Indonesia must give great efforts so that the social insurance which is dignified may be established (Budiono, 2016, p. 9) and that all citizens may access health services evenly and with justice. One basic principle of health development is that each person has the same right to achieve the highest form or health, regardless of tribe, group, religion, and social as well as economic status (Rachmat, 2018, p. 11). The National Health Insurance Program (JKN) frees the people form financial burdens when they are sick whether they are rich or poor (Hasanah, 2017). Based on the explanation above, thus the research problem is, "How is the ideal concept of National Health Insurance for Indonesia?"
2.Methods
This research used juridical normative methods and library research approach. This research is also a prescriptive study, which aims to offer solution towards the problems in the Indonesia's national health social security.
3.Research Results and Discussion
The discussion on social insurance cannot be separated from the history of how this social insurance appeared first hand in the United States of America in The Social Security Act year 1935 to solve the problems of unemployment, senior citizens, sick people and children as a result of the great economic depression. Even though the establishment of social insurance in the developed countries has recently experienced change, basically the establishment of the social insurance in those countries is understood as a real form of the state's protection towards its citizens (Mudiyono, 2002, pp. 68-69).
As explained by Cheyne, O'Brein and Belgrave (O'Brien & Belgrave, 1998, p. 176), social insurance is the execution of the state's social function to its citizens. This social function is an obligatory service from the state, and this function is not based on economic area. The state will not consider profit and loss in undergoing social insurance for its citizens. Thus, as it is not based merely on economic areas, the social insurance is not a way to obtain financial profits for the government or the state apparatus. Below is the essence of what we know of this 'social insurance':
"First, as a system of state financial support that is paid to those persons who are not provided for adequately by the market. Second, as a system of state financial support paid to those persons who are unable to secure adequately."
The state runs its health protection function to its weak citizens by giving financial support, namely the health insurance system, which is ran in Indonesia through BPJS (Badan Penyelenggara Jaminan Sosial)/ Health or other mechanisms. Indonesian citizens have the right to obtain this insurance when they are in an insecure condition, for instance when their sources of income, like the work opportunities are rare. Apart from that, compensation is given to other weak groups which are unlucky, such as those with certain physical conditions (disabled, sick, pregnant) which makes them unable to receive income or to pay for the basic health services.
Government-sponsored social security, including the national health insurance emerged about a century ago with providing effective protection, particularly coverage and cost distribution. The Government Intervention on the social welfare systems have grown to account for substantial portions of government budgets as a duty of welfare state. The government also typically develop an explicit plan showing that projected revenues are sufficient to finance projected expenditures for several years into the future (or, if revenues are not sufficient, explaining how the government proposes to balance projected receipts and scheduled benefits) (Thomson, 1994, pp. 10-11).
There are differing opinions on how social welfare (in this case is the health insurance) should be established. Should it be applied universally to all citizens, or should it only be given to some groups of citizens (selective, like only to the poor, the displaced, and those who pay)? Another debate is on what form the national health insurance should be given: basic treatments, benefits in cash, follow-up treatments, or benefit in-kind?
Countries with a developed state-administration system have detailed information on each of its citizens' bank accounts. In countries with this condition, citizens with certain criteria which have been determined will periodically receive income transfers from the state. Even so, not all social welfares are given in the form of money. There are some state compensations which are given in the form of non-cash (in kind) as well as services: health services, education, housing, etc.
The concept of social welfare in a welfare state is usually based on the principle of equal opportunity, equitable distribution of wealth, and public responsibility from the state to those who are unable to pay their own minimum needs to obtain worthy health services or groups of the weak (McLean, McMillan, & State, 2009).
One of the government's effective means to intervene is through the financial policies (the state budget/Anggaran Pendapatan dan Belanja Negara/APBN) which allocates significant budget for public needs in the health sector including aide programs in the form of the National Health Insurances as an effort to erase poverty (Sugema & Anggraenie, 2009, p. 323).
The social welfare program which are allocated in the state's budget in the form of the social insurance system and the national health system functions as a social protection. Without a system which insures health funding for citizens, thus more and more people will not be able to obtain the health services they need. With the tendency of increasing living costs, including the healthcare fees, thus this will increase the difficulty of the citizens to access health services which they need, especially when they must pay for the fees themselves (out of pocket) in the system of fee for services (Kadarisman, 2015, pp. 474- 475).
The aim of health services as written in the mandate of the Health Constitution is to increase awareness, desire, and ability to live healthily to obtain the highest degree of social health as an investment to develop productive human resources socially and economically. The health insurance is an insurance in the form of health protection so that its participants may achieve the benefits of healthcare and protection in achieving the basic health needs (Mas'udin, 2017, p. 112).
The establishment of the social welfare program in Indonesia is a form of healthcare for its citizens through the National Health Insurance Program which is established by BPJS. The execution of the National Health Insurance Program based on the Constitution Number 24 Year 2011 on BPJS also states that the National Social Insurance is executed by BPJS, which include BPJS Health (Nuryartono & Saparini, 2009, pp. 283-284). Concretely, the state is responsible in giving health services as well as basic health needs for its citizens to a certain extent. The state has a responsibility to solve social, economic, and health issues faced by the citizens (Kartasasmita, 2002, p. 13).
As a state, Indonesia has the main responsibility to provide healthcare and welfare to its citizens. The state must insure the health rights of its citizens are achieved (Zain, Yurista, & Yuniza, 2014, p. 72) by managing the National Health Insurance and also contribute in its payment. The social welfare system and the National Health Insurance are some of the efforts to develop and to give social protection as a way to make the citizens prosper.
If the Indonesian National Health Insurance is said to be a national social insurance, in reality it is an unideal paradox. The Constitution obligates the state to build a Social Insurance system for all citizens. The form of Indonesia's National Health Insurance may not be able to fulfill all of the citizen's rights to obtain social insurance. Only those who pay will obtain such services.
In reality, the social welfare is a human right and the state must fulfill it, but in the Constitution of the National Social Welfare System (UU SJSN/ Sistem Jaminan Sosial Nasional) and the Constitution of the Social Security Administrator (UU BPJS) which uses the social insurance mechanism, the state has changed it so that it is the citizens' obligation to participate in this insurance. The state should have a dominant role in the establishment (i.e. in the payment) of the National Health Insurance in increasing the budget allocation for health, which is still currently only as low as 5%, as it is the state's responsibility (Kadarisman, 2015, p. 469).
In the execution of the National Health Insurance concept, the state is only a facilitator between the citizens and the Social Security Administrator with the concept of insurance (the official form of BPJS is as a public administrator). The state positions itself as the insurance's agent and has the role as a supervisor to the granting of rights for social welfare from employers or from the citizens, instead of as an insurer in the social welfare system (Winarto, 2012, p. 22).
The state should also be present in the National Health Insurance a fix the INA CBG scheme, making it more responsive, so that the National Health Insurance will not become a burden of the health facilities, which will end up as the bankruptcy of the health facilities or the rejection of JKN-BPJS patients.
The role of BPJS in the Constitution of the National Social Welfare System (UU SJSN) and the Constitution of the Social Security Administrator (UU BPJS) automatically weakens the position of "every citizen" maybe stigmatized as the state's "arrogance" (Wahid, 2012, p. 66). The state positions itself and BPJS in the superiority level and has the sovereignty as a "giver", sponsor, a helping god, as well as a debt collector. The concept of BPJS as a public administrator which has the role to manage and to bind the society, and also gives sanctions to the citizens is a paradoxical concept which must be eradicated. BPJS in JKN must be responsive as it must become a way for the state to give social services.
The practice of threatening with sanctions, both in the form of fines and the abolition of certain services to the citizens as applied in the JKN must be banned as sanctions do not actually exist in the concept of social insurance. The practice of threatening with sanctions and the coercion of the citizens to pay for the JKN fees, and at the same time the state only allocates a small amount of budget for health is not an ideal social insurance, and it is not even worth to be called social welfare. Indonesia must not give up its responsibility and force the citizens to pay for the JKN fees.
4.Conclusion
The state must take a dominant portion of payment for the JKN by allocating a higher amount of budget. The lack of funds after the state takes a dominant portion may be fulfilled from the wealthy citizens' contributions as a form of the citizens' participation because anyhow the JKN payment needs a large amount of money.
The social welfare system in all countries is generally organized and it has become the responsibility of the state to pay for it. The JKN program is a form of universal health insurance where the citizens' health fees are supported by the government. If by some reason the state's fees cannot fulfill all fees, thus the state takes the largest portion in the form of national health insurance using the social insurance scheme, a united system between payment from the government and the citizens' obligation. The use of the social insurance mechanism of the social savings which are obligatory (or compulsory insurance) is paid from contributions which are paid by the participants.
Acknowledgement
This article was Supported by LPDP (Lembaga Pengelola Dana Pendidikan) Indonesia.
References
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