全民健保民營化的政治邏輯

The Political Logic of Privatizing Taiwan's National Health Insurance

林國明(Kuo-Ming Lin)

《臺大社會工作學刊》 2期 (2000/05) Pp. 55-96

摘要

本文分析行政院提出的全民健保民營化方案的起源、性質和可能產生的後果。作者首先討論民營化的三種邏輯：強調市場競爭效率的經濟邏輯，民間自主參與的社會邏輯，和解除政府負擔的政治邏輯，並進而指出，行政院的健保民營化政策，雖然使用了提高經濟效率、擴大社會參與和增加民眾選擇等修辭，但它主要動力是想藉由重大決策過程的「去政治化」來追求財務的平衡。而這個民營化政治邏輯的起源，在於政府缺乏行政與政治能力來控制醫療成本和處理調整成本負擔所引發和可能引發的反對與衝突。本文也從比較長期的歷史視野，來分析政府能力的限制，如何受到保險體系的制度特質與政治體系的影響。
本文的分析以為，行政院的民營化政策，不但無法解決成本控制的問題，反而將造成本的上漲、醫療保險體系的階層化、社會團結基礎的毀壞、福利保障範圍的縮減，以及公共參與的減弱。面對這些可能的後果，本文的結論指出，全民健保的改革，應該是在維持公辦公營單一體制下，提升政府的行政監督能力，強化界定集體權益和協調資源分配衝突的民主參與，而非為了財務平衡，去建立一個帶來社會負面後果的民營健保體制。

關鍵字

全民健保 ； 民營化 ； 醫療保險的財務制度與成本控制 ； 社會政策與政治

並列摘要

Taiwan's government is trying to privatize the state-managed, single-payer system of national health insurance, with the view of turning it into a privately-managed, pluralistic structure of administration. This paper analyzes the origins, nature and possible consequences of the government's privatization proposal. It is argued that, despite the policy rhetoric of improving efficiency, enhancing societal participation and increasing options of choice, the major motive of the government's privatization policy is to de-politicize the decision-making process of the national health insurance in order to achieve fiscal balance. I further argue that this ”political logic” of privatization has been originated from the government's lack of administrative and political capacities to control the medical costs and manage the conflicts involving in the readjustment of costs. Presenting a long-term historical view in this paper, I examine how the government's capacities have been constrained by the institutional features of health insurance systems and the polity.
I also evaluate the possible outcomes of the privatization policy, and point out that the privatization policy will increase system costs, reduce social benefits, and undermine solidarity and social equality. With these possible outcomes in minds, I conclude that policy reform in Taiwan's national health insurance should strength governmental capacities and democratic participation, instead of privatizing the state-managed, single-payer system.

並列關鍵字

National Health Insurance ； Privatization ； Financing and Cost Containment of Health Insurance ； Politics and Social Policy