Policy Analysis of the National Health Insurance Program in Budget Deficit Problems And Its Implication to guarantee patient Covid-19

The purpose of this study was to analyze and describe the budget deficit for the national health insurance program on the quality of service for patients with Covid-19. The method used in this research is a qualitative oriented library research with secondary data sources and analyzed based on the theory of policy stages analysis William N. Dunn. The results show that the National Health Insurance program has not found a solution to the problem in dealing with the budget deficit after the tariff increase in Presidential Decree Number 75 of 2019 which was canceled by the Supreme Court for violating the provisions of the 1945 Law article 28 H paragraph 1. So that to cover the deficit is done by APBN and APBD funding assistance efforts. In addition, the handling of covid-19 patients who are instructed to be borne by the BPJS has regulatory constraints that are contrary to Presidential Decree Number 82 of 2018 article 52 paragraph 1 letter O. Policy stages analysis identifies that the problem of budget deficit and inadequate quality of Covid-19 services is triggered by the policies that do not map out the definitions of the problem and the alternatives that will be carried out.


INTRODUCTION
One indicator of community welfare in a nation can be viewed from a health perspective.A healthy society will always support the progress of a country.It should be realized that a healthy lifestyle will support the human development index which will certainly have a positive impact on the development of a country.This requires support from the government, the private sector and the community itself.The attention of the Indonesian government in the health sector is contained in the 1945 Constitution article 28 H paragraph (1) which states that; Everyone has the right to live in physical and spiritual prosperity, to live and to have a good and healthy living environment and to have the right to health services.Based on the law, health insurance is a right for all Indonesian people that must be fulfilled in carrying out the life of every citizen.Optimization of health insurance in Indonesia has been going on for a long time, its implementation starting from the Jamkesmas (Community Health Insurance, 2020) program until in early 2014 its implementation continued to become the National Health Insurance that Health Insurance is a guarantee in the form of health protection so that participants receive health care benefits and protection in meeting basic health needs that are given to everyone who has paid health insurance contributions or health insurance contributions.paid by the central government or local government.Then it is explained in article 2 that health insurance participants include Contribution Assistance Recipients (PBI) and Non-PBI Participants (Non PBI).
The National Health Insurance is real evidence as an effort to meet the needs of the community in the health sector.Through JKN the community is given easy access to health services without paying a fairly high cost.Because with JKN payments are made every month by registering as a participant.Thus, when people experience health problems, the public will not be charged health fees again.The existence of health insurance is very helpful for many people, this can be seen from the number of participants of the JKN program which continues to boom.Quoted on the official website bpjs-kesehatan.go.id, the JKN participants as of February 29, 2020 are as follows: The increase in the number of participants every year continues to increase, causing the Health Insurance Administration Agency (BPJS) budget to experience a deficit.The BPJS budget deficit has not only occurred once, but has occurred since the beginning of 2014.Since it was first established BPJS Kesehatan has always experienced a budget deficit every year.The cause of the BPJS Health budget deficit, which is mentioned on the katadata.co.id data quantification page, is that the number of participants for the National Health Insurance (JKN) program in 2019 is relatively high, up to 221.23 million people and is not comparable to the payment of non-current contributions.not being disciplined in paying and even committing fraud, such as registering when sick and stopping when healthy, besides the burden of financing for catastrophic (high-cost) diseases continues to increase.
The budget deficit causes the government to take strategic steps in dealing with the growing deficit.One of the efforts is to increase tariffs.The tariff increase has been approved by the government through Presidential Regulation Number 75 of 2019.In Article 34 of the Presidential Regulation Number 75 of 2019 the new tariff for class I is IDR 160,000, class II is IDR 110,000 and for class III is IDR.42.000,-.The increase reached 100% even more than the previous tariff for class I of Rp. 80,000, -, Class II of IDR 51,000, -and class III of Rp. 25,500, -.The increase in health insurance rates is considered burdensome for the community and reaps the pros and cons.The government's control of wanting to close the budget deficit by increasing tariffs was canceled by the Supreme Court after receiving a claim from the Indonesian Dialysis Patient Association (IPCDI) and was deemed to have violated the legal provisions between Presidential Decree No. 75 of 2019 and UU 1945 Poin 28 H.
The problem of the budget deficit has not yet come to light, but problems in the health sector continue.On March 2, 2020, as it has been reported in various media, that the COVID-19 pandemic has entered the territory of Indonesia, it is increasingly worrying various groups.Data compiled from covid19.go.id as of March 28, 2020, the total number of positive cases in Indonesia reached 1046 cases, namely 913 in treatment, 46 people were declared cured and as many as 87 people died.In dealing with this case, the government has taken various ways, one of which is related to this article, namely the government will bear the cost of treating COVID-19 in hospitals through BPJS Kesehatan, of course, provided that the patient has been registered as a JKN participant.However, this statement contradicts Article 52 paragraph 1 letter o of Presidential Regulation Number 82 of 2018 concerning Health Insurance as health services do not guarantee health services due to disasters during the emergency response period, extraordinary events/epidemic.Meanwhile, COVID-19 is a global pandemic that has spread throughout the country and cannot be separated from the attention of the World Health Organization (WHO).
In addition, the failure to increase tariffs will affect the condition of JKN participants, especially the quality of service for COVID-19 patients.According to (Nurhadi et al, 2020) the quality of a company is the same as the value given to improve the quality of life of customers.The higher the rating, the greater the customer satisfaction.In this case, BPJS which oversees JKN will determine services in the health sector.In line with this (Abidin, 2016) assesses service quality aspects in three respects, namely reliability, the ability of health workers to provide promised services on time and satisfactorily.Responsiveness is the ability of health workers to provide responsive services, and empathy includes the ease of making good communication relationships and understanding the needs of patients.
Patients as external customers not only want healing from the results of services, but also feel and assess how they are treated in the service process (Sanusi, 2017).In fact, it was formed because of the principled management as a basic guideline and mental attitude in running the organization, in this case BPJS, which has an important role.As stated by (Trisna et al., 2017) that BPJS provides a mechanism that can increase the public's affordability to health facilities.the reach of health facilities is expanded to be able to serve the lower middle class and not only the upper middle class.This study tries to answer the problem of the JKN budget deficit on the quality of service for COVID-19 patients based on an analysis of the public policy process.The identification of research findings in the analysis of the policy process in the JKN program resulted in the identification of conditions arising from policy problems.Where there is an imbalance between the deficit and the quality of health services as well as contrary to Presidential Regulation Number 82 of 2018 article 52 paragraph 1 letter O which actually does not facilitate health insurance for patients due to the outbreak.

RESEARCH METHODS
This study was explored using qualitative methods with library research, oriented to literature review sources related to the problem of the JKN program budget deficit and the quality of service for COVID-19 patients.Secondary data collection is carried out by documentation based on literature reviews originating from official websites, books, journals and information obtained from online media and print media (Zed, 2004).The collected data was then analyzed based on the policy stages analysis of Wiilliam N. Dunn.In Dunn's view, the policy analysis method combines five general procedures commonly used in problem solving as follows (Dunn, 2003): a. Definition, which produces information about the conditions that give rise to policy problems.b.Prediction, which provides information about the future consequences of implementing policy alternatives, including not doing something.c.Prescription, which provides information about the value of alternative future consequences.d.Description, which produces information about the current and past consequences of implementing policy alternatives.e. Evaluation, which shows the usefulness of alternatives in problem solving.(Yudiatmaja, 2016)

RESULTS AND DISCUSSION
Problem definition relates to information that causes problems (Dunn, 2003).In this case, Indonesia's national health policy has entered a new phase of problems.According to the 2016 Executive Summary of the Program Management Report and Health Social Security Financial Report (BPJS Kesehatan, 2016) there is a fundamental problem that the premiums that must be paid by participants are not in accordance with the calculations of experts or not according to the actuarial calculations commonly used in programs like this.This condition creates an underfunded program situation which in a structured way will affect the sustainability of the health insurance program.The challenge for the National Health Insurance program is currently faced with the issue of the level of financial health of the Social Security Fund (DJS) which is in deficit due to the insufficient amount of contributions compared to the size of the benefits specified.
The number and mix of participation that are always in the opinion of will be able to solve the problem of adequacy of funds when all healthy participants join and the entire population of Indonesia has been registered as participants of the National Health Insurance, after being calculated it is proven that they cannot cover the deficit.The government's step to cover the deficit is to increase tariffs, increasing tariffs is an effort that is considered to cover the deficit because the injection of funds from the government is no longer helping to cover the deficit.The increase in the National Health Insurance rate was ratified in the Presidential Regulation of the Republic of Indonesia Number 75 of 2019.However, the Supreme Court won the demands of the Indonesian Dialysis Patient Association (IPCDI) and canceled the increase in the National Health Insurance rate because it was deemed not in accordance with the 1945 Constitution article 28 H. Thus, the government is required to make new rules and cancel Presidential Decree No. 75 of 2019.
In addition, the budget deficit has not yet seen a bright spot, but has been burdened again after President Jokowi announced on March 2, 2020 that there was the first COVID-19 case in Indonesia.The initial spread of COVID-19 came from Wuhan, Hubei Province of China.At first there was a patient in the area suffering from a rare disease (corona) which later every day the Chinese government always received the same type of complaints.The World Health Organization (WHO) claims that COVID-19 is a pandemic that cannot be underestimated because its spread has reached all over the world.The positive number of COVID-19 which has reached thousands of millions of people is more for the government to provide optimal health services.The new step of choice is for Covid-19 positive patients, the financing is borne by BPJS Health.Thus, the burden of budget allocations will further widen the deficit.Although it is natural that it is the responsibility of the government, on the other hand there must be a legal basis and regulations to review it.In addition, COVID-19 is considered an extreme outbreak whose handling requires specific services.Health workers, medicines, vaccines, and other medical devices are also needed by hospitals, which are currently in limited numbers so they also require additional costs for the services of COVID-19 patients.

Prediction of the Sustainability of the JKN Program
In this case the prediction relates to the assessment of alternatives to be chosen from problem solving.The alternative that will be carried out by the government to help fund COVID-19 patients and minimize the BPJS Health budget deficit in addition to increasing rates is through APBN and APBD funds.As found on the CNN Indonesia media page, it is stated that there is a local government responsibility that is expected to help BPJS Health in covering the costs of treating COVID-19 patients which is absorbed from the Regional Revenue and Expenditure (APBD) budget allocation to support BPJS health financing.So from this effort the regional government needs to divert budgets that are not prioritized for the needs of handling COVID-19 patients.Of course, this is the same as the central government to divert non-priority spending from the state budget to prioritize COVID-19 patients.However, the consequences of this assistance do not guarantee that all COVID-19 patients are fulfilled in health services.This is because the provisions for obtaining JKN health services must be registered in BPJS membership where most of the Covid-19 patients are not included in the BPJS health membership because the financing burden that must be paid every month is quite burdensome.

JKN Program Prescription
JKN program prescriptions relate to the assessment of the chosen alternative.The author's analysis in this case is the policy of budget assistance through the APBD and APBN to the BPJS health as the National Health Insurance institution.The implementation procedure cannot be carried out immediately because this will violate the legal provisions of Presidential Regulation Number 82 of 2018 article 52 paragraph 1 letter O which does not guarantee health services related to the outbreak.The COVID-19 pandemic itself is an epidemic that cannot be ignored because it has been proven by the number of deaths around the world which is quite worrying.In addition, various losses have been caused by Covid-19 such as the cessation of several community activities, declining economic stability and even health threats for everyone where this outbreak is rapidly spreading.For this reason, the main problem that needs to be taken is adequate health services because it involves the survival of every human being.If basic services are not carried out properly, the budget issued by the government as Covid-19 assistance will be in vain and the consequences will trigger material losses considering the sizeable impact of COVID-19 on economic growth as well as the welfare of many people.While the chosen alternative requires regulatory reforms that require BPJS to be able to bear and provide budget absorption through JKN for COVID-19 patients.Otherwise, policy implementers in the field will be faced with difficult situations due to poorly programmed procedures.

JKN Program Description
The implementation of health insurance for COVID-19 patients through the JKN program which was canceled by the Supreme Court (MA) had implications for the quality of service for Covid-19 patients.The government's plan to bear the burden of insurance costs for Covid-19 patients must be implemented wisely.Procedures for service, treatment and distribution of funds for hospitals are immediately allocated with the principle of convenience, namely efficiency and effectiveness of performance.The budget issued by the government through the APBN and APBD itself requires intensive supervision.Do not let the allocation of funds large enough for the handling and guarantee of Covid-19 patients to be used by irresponsible persons to seek profit in the midst of this very important problem.
In addition, it is a priority for the government's attention that the handling of COVID-19 must pay attention to two points of view.First, services for COVID-19 patients need to be balanced with medical personnel facilities and equipment where there are still many medical professionals who lack medical aids.This limitation is triggered by a large number of requests but the amount of production is getting smaller because it is needed by many countries.In addition, inadequate rapid test kits were also triggered by delays in imports which were only ordered after there were COVID-19 victims.Thus the government has no reserves.
On the other hand, the Indonesian people are cheating and are concerned with personal gain by hoarding masks which should be more important to be used by the majority of the medical team.Meanwhile, from the second point of view, it is necessary to pay special attention to people who have not tested positive for COVID-19.By following the example of South Korea by conducting mass tests in the form of extensive and effective testing.The tests did not take long because the government cooperated with private companies to work effectively and efficiently.Thus, if this can be done wisely, the national health insurance will not have a heavy enough burden in dealing with COVID-19 patients and can minimize the occurrence of a spike in the budget deficit.

Evaluation
The assessment of solving the problem, namely the BPJS health budget deficit for Covid-19 patients, must be passed by revising the legislation.There are several rules that must be revised, such as Presidential Regulation No. 75 of 2019 concerning changes to Presidential Decree No. 82 of 2018 concerning Health Insurance because the increase in JKN rates is contrary to Article 28 H paragraph 1 which reads; Everyone has the right to live in physical and spiritual prosperity, to live and to have a good and healthy living environment and to have the right to health services.Presidential Decree 75 of 2019 is not in line with the agreement of the law that good health services are the rights of every community that must be fulfilled.It is supported again in the statement of Article 28 H paragraph 2 which states that everyone is free from discriminatory treatment on any basis and is entitled to protection against such discriminatory treatment.This means that the increase in tariffs has burdened some underprivileged groups.In addition, Presidential Decree Number 75 of 2019 indirectly discriminates against the poor because the tariff burden is quite high, as if it regulates that small people are prohibited from getting sick.
The cancellation of Presidential Decree No. 75 of 2019 by the Supreme Court provides homework for the government in regulating the health insurance budget that is facing a deficit problem.What's more, the implications for the global COVID-19 pandemic.The government's statement regarding Covid-19 patients as health insurance is borne by BPJS violates the applicable provisions, namely Presidential Regulation Number 82 of 2018 concerning health insurance article 52 paragraph 1 letter O, namely health services due to disasters during the emergency response period, extraordinary events/epidemic.Even though the injection of funds for COVID-19 patients comes from the APBN and APBD through BPJS, this still violates applicable legal provisions.The main solution that must be passed is to quickly revise the applicable regulations in order to carry out optimal policy implementation.Based on the policy stages analysis presented, it was found that the problematic results of the BPJS Health budget deficit which have implications for Covid-19 patients include: a. Health services for COVID-19 patients are considered not optimal, it can also be seen between the number of recovered patients and dead patients who are not balanced.c.Need a Long Term Alternative; Two problems between the budget deficit and health services for COVID-19 patients require long-term alternatives.This is done to prevent similar incidents from happening again.A long-term alternative in handling the BPJS Health budget deficit can be by increasing the excise duty on goods that interfere with health.
While the long-term alternative in handling Covid-19 patients is to conduct mass tests early and the results can be known quickly.In addition, the best alternative to the two implications between the BPJS budget deficit and the handling of COVID-19 patients is to revise the old rules into new rules that can solve the problem.

CONCLUSION
Based on the results of the discussion above, it can be concluded that the BPJS health budget deficit in the National Health Insurance program for COVID-19 patients has an impact on health services.Health services for COVID-19 patients require special efforts that must be handled with JKN financing facilities.Budget injections through the APBN and APBD are expected to reduce the spike in the BPJS health deficit.However, in addition, the implementation is still stalled because there is a legal discontinuity in Presidential Regulation Number 82 of 2018 article 52 paragraph 1 letter O which states that health insurance is not enforced due to the outbreak.Therefore, the handling of COVID-19 patients through the JKN program is pressed by existing regulations.From the discontinuity of these regulations, it was found that there were still many patients affected by COVID-19 who received inadequate service quality, including medical personnel and hospital facilities.Meanwhile, in the case of a budget deficit, it is possible that it will continue if the alternative for budget injections is only through the APBN and APBD which are very limited in number.For this reason, other efforts are needed, such as allocating tax or excise funds for goods that interfere with health to help cover the BPJS budget deficit whose accuracy.
ISSN 2798-4494 (Print), ISSN 2776-6861 (Online) Volume.01 Issue.01, Page No. 23-30, April, 2021 DOI: https://doi.org/10.31629/jmap.v1i1.3326 ) program under the auspices of the Health Social Security Administering Body (BPJS).BPJS as mentioned in Law Number 24 of 2011 concerning Social Security Administering Body is a legal entity established to administer social security programs.It is reaffirmed in the Presidential Regulation of the Republic of Indonesia Number 82 of 2018 concerning Health Picture 1. JKN Program Participants As of February 29, 2020Source : https://bpjs-kesehatan.go.id/bpjs/ (processed by researchers, 2020) Picture 1.2 BPJS Health Budget Deficit 2014-2019.Source: https://katadata.co.id (processed by researchers, 2020) The government does not yet have clear legal regulations; Health insurance for COVID-19 patients has not clearly provided legal regulations.Especially in Presidential Decree Number 82 of 2018 concerning health insurance article 52 paragraph 1 letter O.In this case the government as an important actor in handling Covid-19 has a role to make new legal provisions in the midst of this very urgent situation.Moreover, a limited budget will also have an impact on everything.Legal regulations in handling budget deficits and handling COVID-19 patients will have an impact on the design of the APBN and APBD budget drafts because COVID-19 has a major impact on financial needs.b.JKN Participant Health Services are not yet Optimal; Prior to the increase in JKN rates, it was assumed that bad services still often occurred, especially in large cases such as COVID-19, it would automatically affect the service.Various media said that in the case of COVID-19, both hospitals and medical teams still lacked medical equipment such as rapid tests, vaccines, personal protective equipment and health masks.The shortage of inadequate health facilities is due to the very limited number.So this affects the service.