“組合”乎？“市場”乎？－從台灣變遷中社會的屬性探索全民健保的體制

Is It Associations or Market?-In Search of a National Health Insurance Model in Light of Taiwan's Changing Society

陳孝平(Michael S. Chen)

《中華公共衛生雜誌》 16卷1期 (1997/02) Pp. 86-108

https://doi.org/10.6288/CJPH1997-16-01-08

摘要

全民健保法的規劃，秉持著「經濟學主義」，在技術層面上相較過去之社會保險有明顯之進步，然而因忽視了「社會面向」及「政治面向」，以致在立法及實施的過程中遭遇到許多橫逆。此緣台灣在解嚴之後，社會力倏忽解放，利益團體風起雲湧，而健保規劃當局未能體察台灣社會的屬性已大異往昔，未致力在法案設計中，建立協和利益衝突的機制，實有以致之。
社會保險因可操作的政策工具有限，而所欲達成的目標眾多，具有「過度認定」的本質：滿足了某些團體，就可能使其它團體的目標落空。在過去威權時代，國家的強制力量可貫徹由官僚制定的政策，然民主化之後，則問題的解決若不是依靠利益團體之問在平等、互惠、長期、持續的原則下協商，就只有委之於市場。前者藉「共治」的機制使利益協和，須有「同舟共濟」的意識；後者雖免於徒須由政府裁斷的問題，然而卻難免產生公平等問題。
「共治」的整合主義模式雖為一相對優良之健保組織模式，然而其前提是該社會必須為一「命運共同體」。若台灣因故無法具備整合主義之條件，或受貿易自由化、產業外移、外勞進入等影響，致無法維護固定的社會疆界，而不能依整合主義建構全民健保模式時，則管理式市場模式即可能成為明知有缺點，但仍不得不接受的最後仰仗。因為捨此而就國家模式，在政府業已無力主導政策時，很可能因無法應付利益團體之索求而陷入財政危機。

關鍵字

全民健保 ； 利益團體 ； 競租

並列摘要

The National Health Insurance Act, passed July, 1994, is a victory of economism and scientism, yet spelled a failure of political economy: Taiwan has entered the post-Confucian era and the civil soiety has unleashed its pent-up power, yet the Act still reserves too many authoritarian elements. In particular, the Act lacks in mechanisms for interest reconcilliation, and leaves too much discretionary power in government's hand. Government, therefore, rendered itself victim of rent-seeking advances from various interests.
A social insurance program often features too many goals and too few tools and therefore, while some segments of the population may be served, many more may be dissatisfied. In the past when Taiwan was still under the Martial Law, it was easy to enforce any social policy through the coercion power of the state; yet in a democratized society, the social order can be maintained only through market or a corporatist structure in which negotiations are conducted based on principles of parity in power, mutual benefit, long term, and multi-issue. A market model may be free of direct intervention from the state, but could entail problems of inequality; and a corporatist model can not do without codetermination and solidarity.
Corporatism based on codetermination is arguable a better model for social cohesion; yet, the precondition is that the society must be a community of common fate, or a society whose boundaries are fixed. Should Taiwan, under impact of globalization of economy, outflow of industries, and inflow of alien labor, can not keep its boundaries unchanged, the corporatist model might not be feasible. A market model, then, becomes a last resort, since the inability of the state to contain interest contlicts might render a social insurance program a ”welfare trap”.

並列關鍵字

national health insurance ； interest groups ； rent seeking