全民健康保險費政府補助款分擔之研究

A Study of the Share of Government Subsidies on the National Health Insurance Premium

張鈺旋(Yu-Hsuan Changa)

指導教授 ： 蘇彩足 ； 李建良

國立臺灣大學/社會科學院/政治學研究所/碩士(2006年)

https://doi.org/10.6342/NTU.2006.02623

摘要

臺灣於84年實施全民健康保險，屬於強制性社會保險，其主要目的係透過保險風險分擔之功能，於被保險人及其眷屬發生生育、疾病及傷害事故時，能適時提供醫療給付，降低人民就醫經濟性障礙，健全國民之醫療照顧。全民健保初期以追求擴大受益人口、增加就醫可近性、節制醫療費用為目標；而第二階段目標則在於照顧弱勢族群、提高醫療品質及平衡保險財務。
由於臺灣的全民健保具有強制保險之特性，所以全民健保之保險費負擔分配，係由被保險人、雇主與政府三方面各負擔一定比例，此乃立法者基於社會安全及公共利益之考量。
依全民健康保險法第27條規定，被保險人及投保單位須負擔全民健保保險費，且各級政府須負擔一定比例之補助款（本文以下簡稱健保費政府補助款），從保險費收入執行情形，被保險人及投保單位之平均收繳率為97.89 %，政府補助款之平均收繳率為92.43 %，亦言之，被保險人及投保單位相較於政府之保險費收繳情形佳，而依照中央健康保險局之統計資料，截至94年12月底止地方政府積欠85年度至93年度之健保費補助款共計達396.44億餘元，94年度部分，地方政府尚未撥付之健保費補助款計66.77億元。
以臺北市政府為例，自88年下半年以後，以歲入減少及統籌分配比率爭議為由，使健保費政府補助款之欠費情形日益嚴重，臺北市政府認為適用健保法第27條規定，發生有牴觸憲法之疑義，經司法院作出釋字第550解釋，地方自治團體對於基本國策之實現，負有協力義務，保險費由地方政府予以補助，符合憲法要求中央與地方共同建立社會安全制度之意旨；健保法第27條所定補助保險費之比例，屬於立法裁量事項，除顯有不當者外，不生違憲問題。
繼而中央健康保險局於92年2月函請各欠費縣市依法提出還款計畫，否則依法強制執行，臺北市政府分別於92年3月提起訴願，同年10月聲請停止執行，11月提起行政訴訟，案經最高行政法院於94年判字第01546號判決：「原判決廢棄。訴願決定及原處分關於命上訴人負擔其行政轄區外居民全民健康保險補助款部分均撤銷。第一審上訴審訴訟費用均由被上訴人負擔」。
健保法規定之各級政府健保費補助款，係中央立法但涉及地方財政的重大法案與政策，固因全民健保為整合性之社會保險，健保之制度設計沿襲原公保、勞保及農保等制度，有其歷史因素，惟本案之最重要關鍵在於統籌分配稅款之改變及中央與地方之財政移轉，所引發之爭議。本文從法律學角度進一步分析研究：
一、憲法規定國家應推行全民健康保險，憲法規定之「國家」任務及「政府」功能為何？二、全民健康保險法為憲法規定之「社會立法」範疇，是否屬「共同辦理事項」？中央與地方辦理事項之職權劃分原則為何？三、全民健保法第27條規定地方自治團體對於全民健康保險之保險費，是否違反費用分擔之一般原則？四、全民健保法第27條規定地方自治團體對於全民健康保險之保險費，其計算基礎應如何始為允當？五、可否建立中央與地方之協商機制？
各級政府負擔健保費補助款仍存有重大爭議，顯然司法判決亦未能終局解決此問題，固然與國庫榮枯、各級地方自治團體之財政收支劃分及計算方式之改變有關外，但整體上吾應更重視攸關全民公共政策議題－全民健保之核心價值，提供全體國民更公平、有效率、高品質的的健康保險服務，並於本文最後提出政策建議，提供予相關主管機關參考。

關鍵字

全民健康保險 ； 政府補助款

並列摘要

The National Health Insurance (abbreviated as NHI) was implemented in 1995. It is a compulsory social insurance, which aims at diminishing financial barriers for the citizens, and to protect the health of all nationals. It provides adequate medical coverage for the insured and his/her dependants when they are happened with baby deliveries, sickness or injury incidents through the risk-sharing functions of the insurance. At the initial stage, the NHI’s goal was set to expand the insured population, increase medical accessibility, and contain medical expenditures; and in the second stage, it was to take care of the disadvantaged groups, improve quality of care, and keep insurance finances in balance.
Because of the compulsory feature of the NHI, premiums are shared by the insured, employers, and the government at specified proportions. It was legislated based on considerations of the social security spirits and public interests.
According to article 27 of the NHI Act, the insured and the insuring group units (usually the employers) should contribute NHI premium, and also different levels of government bodies should contribute certain amounts of subsidies (mentioned as NHI government subsidies hereafter). In terms of premium collection, the collection rate of premiums contributed by the insured and the insuring group units is 97.89%, and the collection rate of government subsides is 92.43%. In another words, the collection rate of contribution by the insured and insuring group units is higher than that of the government. According to the statistics of the Bureau of National Health Insurance, the accumulated debts of district government agencies from 1996 to 2004 reached NT$39644 millions by Dec. 2005. For 2005, premium dues of district government agencies totaled NT$6677 millions.
Taking Taipei City Government as an example, their premium arrearage becomes higher in the second half of 1999 due to reduced tax revenues and unsettled arguments in the overall government budget allocation issue. Taipei City Government argues that article 27 of the NHI Act is in conflict with the R.O.C. Constitution. The Judicial Yuan has interpreted it by No. 550 Explanatory Note that local governments bear responsibilities for coordinating the realization of basic national policies; which meets the intention of the constitution to request the coordination of central and local governments to co-establish social securities. And the proportion of premium subsidies stipulated in article 27 of the NHI Act is a legislative decision, and it does not collides with the constitution unless there is an obvious inappropriateness.
As a result, the BNHI noticed every city or county governments owing premium contributions for submitting a payback plan; otherwise cases will be referred to the courts for compulsory enforcement. Taipei City Government pleaded in March 2003, applied for withholding the execution of compulsory enforcement in October, and brought an administrative litigation in November. The case was decreed: “the original decision is to be abolished” by the highest administrative court by verdict number 01546.” The decision of the pleading and the original decision about ordering the appellant to be responsible for premium subsidies for citizens living outside of its jurisdiction were all withdrawn. The related fees for the first trial should be born by the appellee.”
The subsidies by all levels of government bodies stipulated by the NHI Act is a major act or policy legislated by the central government and related to local government’s finances. Because the NHI is an integrated social insurance, the NHI system has inherited practices of the Government Employees Insurance, Labor Insurance, and Farmers’ Insurance due to historical factors. But the most important key in this case is the controversy resulted from the change of overall government budget allocation and the financial shift between central and local governments. This paper analyzes further from the perspectives of law:
1. It is stipulated in the constitution that the nation should implement national health insurance, but what are the “nation’s” tasks and “government” function as stated in the constitution?
2. The NHI Act is in the scope of “social legislation” as regulated in the constitution, but does it belongs to the “jointly handling matters?” How to divide the authorities in jointly handling matters between the central and local governments?
3. Does the premium share of local governments as regulated in article 27 of the NHI violate the general rule of cost sharing?
4. What is an appropriate base to calculate the premium contributed by local governments as stated in article 27 of the NHI Act?
5. Is it possible to establish a negotiation mechanism for the central and local governments?
There are still major disputes over premium subsidies among all levels of government agencies, and apparently, the judicial verdict had not solved this problem eventually. Although it is related to the growth and decline of the national treasury, and the change of allocation and calculation methods of different levels of local governments, in overall, we should pay more attention to the public policy issue that affects the whole citizens – the core value of the NHI – to provide a more efficient, equitable, and high quality National Health Insurance. At last, the author proposes a policy recommendation for the reference of related authorities.

並列關鍵字

National Health Insurance ； Government Subsidies

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