中央健康保險局組織體制改革決策過程之研究

The Study of Organization Reform Decision-Making Process of the Bureau of National Health Insurance

彭巧菁(Chiao-Ching Peng)

指導教授 ： 張四明

國立臺北大學/公共事務學院/公共行政暨政策學系/碩士(2008年)

摘要

我國全民健康保險自實施以來，達成全民有保、綜合照護、費用低廉、民眾滿意度高等多
項成就，惟因近年來全民健保財務失衡，社會各界對於中央健康保險局的財務績效有著許多質
疑，健保局員工領取年終獎金也屢遭抨擊，讓健保局、衛生署乃至行政院均承受不少壓力。
健保局現行公辦公營的單一保險人體制，從規劃初期、立法階段乃至開始實施時，一直受
到許多挑戰與質疑，也曾遭遇「民營化」、「多元化」及「市場化」等潮流的衝擊，惟迄今仍難
以有結構性的變革。依政府2007年最新的改革構想，健保局將朝行政機關改個革，為何政府選
擇將健保局改為行政機關？決策的過程為何？是本研究想要探究的問題。
本研究以 John. W. Kingdon（1984）所提出來的多元流程模式－問題流程、政策流程及政
治流程作為研究架構，而研究方法主要採用「文獻分析法」與「深度訪談法」，並輔以研究者
親身參與觀察的經驗。研究過程中，大量蒐集期刊文章、書籍、論文、研究報告、報紙與立法
院公報，並且訪談各方代表，進行資料的整理、比對與分析，獲得以下的結論：
ㄧ、健保雙漲事件揭開健保財務黑洞，引爆民眾憂慮及不滿。
二、績效獎金爭議凸顯沉痾已久的健保體制問題，啟動健保組織改革的機會之窗。
三、行政機關改革方案的產生，頗能呈現「政策原湯」的特質，但最終獲選的政策方案與學者
專家的提案大相逕庭；健保局員工是行政機關改革方案的主要參與者；行政機關方案的可
行性高於行政法人方案。
四、媒體及立法院是健保局組織改革政治流程中的要角，利益團體在健保局組織改制過程中的
角色相對中性，而政黨的影響力則顯而易見。
五、三股流程完全匯合方才開啟「政策之窗」，而內閣改組是組織體制改革的關鍵時機。
六、政策企業家在不同的流程匯合上扮演重要的角色，除了政府官員、立法委員、健保局
員工外，媒體也是積極的政策企業家。
七、健保局改革決策過程中理性與非理性因素並存，因此多元流程模式裡仍會出現片段的理
性。
八、問題流程、政治流程及政策流程並非完全獨立，毫無關連。
九、多元流程模式的分析架構及機會模式觀點（政策之窗）是適用於健保局組織改革政策的決
策過程，但未必能正確適用在其他政策的決策過程。

關鍵字

健保局組織；決策過程；多元流程模式；政策之窗；政策企業家

並列摘要

Since the implementation of National Health Insurance (NHI) in our country, targets
such as “NHI-for-all”, “comprehensive medical care” “affordable fees”, and “high
satisfaction level” have been accomplished. However, due to the financial imbalance of
NHI, people from all walks of life queried the financial performance of Bureau of
National Health Insurance (BNHI). There had also been frequent criticisms regarding
year-end bonuses given to BNHI employees. As a result, the Dept. of Health, the Health
Bureau, and the Executive Yuan were all put under tremendous pressure.
The public managed public insurer system had often received challenges and
queries from its early planning, legislation, to implementation. Since it was also subject
to impacts of “privatization”, “diversification”, and “market-driven” trends, structural
reforms have not been possible as of date. According to the government’s latest 2007
reform plan, The BNHI will reform into an administrative agency. This research will
focus and probe into: 1. The reasons why the government chose to change the BNHI into
an administrative agency; and 2. The policy setup process.
The framework of this research covers the multiple streams model proposed by John
W. Kingdon (1984) that consists of the problem stream, the policy stream, and the
political stream. The documentary analysis method and in-depth interview are adopted as
the study methods based on the researcher’s experience in personal participations and
observations. During the study process, large quantities of journal articles, books,
dissertation papers, study reports, newspapers, and journals from the Legislative Yuan
are collected. Moreover, representatives from all circles are interviewed. The data is then
compiled, compared and analyzed to obtain the following conclusions:

1. The co-payment rate issue disclosed the hidden truth about the financial status of NHI
and aroused people’s anxiety and dissatisfaction.
2. The dispute over performance bonus has made the health insurance system a problem
of concern, which draws the opportunity to initiate organization reform.
3. The formulation of the administrative agency reform plan is able to present
characteristics of the “policy primeval soup.” The final policy plan chosen is entirely
different from plans proposed by researchers and experts. Employees of BNHI are the
main planners of the administrative agency reform plan. The feasibility of the
administrative agency plan is much higher than the administrative institution plan.
4. The media and the Legislative Yuan play essential roles in the political stream of the
NHI organization reform plan. The role of interest groups is relatively neutral
throughout the BNHI organization reform process. The influence of political party
involvement is apparent.
5. The three streams are completely integrated to initiate the “policy window” of the
Executive Yuan. Meanwhile, cabinet reorganization is the crucial time of opportunity
for BNHI organization reform.
6. The policy entrepreneur plays an important role in policy formulation. Other than
government officials, legislators, and BNHI employees, the media are also active
policy entrepreneurs.
7. During the BNHI organization reform decision-making process, both rational and
irrational processes exist. Therefore, parts of rational processes will be present in the
multiple stream model.
8. The problem stream, political stream, and policy stream are not completely
independent or unrelated.
9. The analytic structure and policy window of the multiple streams model are applicable
in the decision-making process of organization reform policies; however, they may
not be applicable in decision-making processes of other policies.

並列關鍵字

decision-making process；multiple streams model；policy window； policy entrepreneur

參考文獻

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