Is universal health coverage really better? Unintended consequences of the 2019 Amendment of the National Health Insurance Act for humanitarian sojourners in South Korea

Background: South Korea achieved universal health coverage (UHC) through the National Health Insurance (NHI). However, humanitarian sojourners under temporary stay permits were initially excluded. Alongside recommendations from the National Human Rights Commission of Korea (NHRCK), the 2019 Amendment of the NHI Act expanded eligibility of the NHI. While this marked significant progress toward greater universality in health care, it also led to unintended consequences for humanitarian sojourners. Methods: This study employed a two-fold approach aligned with the trajectory of the Amendment. First, we conducted semi-structured in-depth interviews to analyze diverse perspectives on the universality of health coverage, the benefits of NHI, and the limitations of policies prior to the 2019 Amendment. Participants included government officials from the Ministry of Health and Welfare, Ministry of Justice, and NHRCK, as well as humanitarian sojourners sharing real-life experiences. Second, we examined the expected and unexpected outcomes of the Amendment by reviewing legal documents, reports, and media coverage after the Amendment. Specifically, we analyzed precedents set by the Korean Constitutional Court regarding the constitutional litigation, white papers, and interviews published in the news. Results: Despite achieving UHC, Korea had limited universality of health coverage prior to the 2019 Amendment, as humanitarian sojourners were excluded from local subscription. The 2019 Amendment of NHI Act expanded eligibility, making local subscription mandatory for humanitarian sojourners. However, unintended consequences emerged from differential treatment in calculating insurance premiums, determining dependents within the same households, and enforcing penalties for missed payments. Such disparities not only continue to restrict access to care but jeopardizes visa extensions for humanitarian sojourners. Conclusions: Our findings highlight a critical gap between policy intent and policy impact, revealing the consequences that disproportionately affect the most vulnerable populations, even under the UHC. Effective implementation of UHC requires a deeper understanding of how government officials and judicial authorities perceive universality and view refugee populations. The discrepancies identified in this study underscore the urgent need for coherent policies that not only expand health coverage but also establish a robust safety net to protect marginalized groups.