South Korea is one of the few countries that has successfully consolidated its national risk pools into a single-payer health insurance system. This study analyzes national health insurance (NHI) consolidation in South Korea between 1980 and 2003, drawing lessons for countries seeking to consolidate their risk pools. The paper contextualizes the development of the South Korean national health insurance system and the consolidation of its risk pools in the changes in the political environment, particularly the processes of political democratization. It examines how these processes have affected the societal meanings and roles of the health insurance system. The paper focuses on two policy stages. During the agenda-setting stage, the government and employers emphasized the efficiency of the health insurance system. This emphasis contributed to the failure of a consolidation plan that emphasized equity over efficiency. However, as democratization expanded, the power of civil society movements and the popular demand for equity grew stronger. During the policy adoption phase, consolidation of health insurance trusts in South Korea was achieved through social and political processes that influenced public opinion, expanded civil society participation in decision-making, and worked with the government to integrate health insurance organizations and funds.