自1995年全民健康保險實施至今,已屆18年,雖然全民健保達成多項成就,但是在財務上卻存在著不公平(六類十四目)與不穩定(費基僵化)的問題,並隨著時間財務問題逐漸深化,然而,全民健保設立至今,財務的調整與改革始終遭遇極大困難。政府對此亦提出二代健保,此是以財務問題為出發並納入其他面向之改革方案,但是卻始終致礙難行,直到2011年1月才完成立法。即使改革法案得以通過,但其中最重要之精神「家戶總所得」卻遭放棄,依舊維持六類十四目並加收補充保險費。本研究即是要探討全民健保之財務改革究竟遭遇何種困境?此種困境所可能的促成轉變之模式為何?以及在特定的轉變模式下為全民健保所帶來之意義為何?本研究透過漸進式的制度變遷論去解釋制度變遷的模式,分析出全民健康保險在財務改革的變遷內涵上可得出兩個變遷模式:2011年前因為財務面的不作為形成了「漂流」(drift)的變遷模式;2011年的「修正版二代健保」則為加層(layering)的模式。漂流的形式顯示了社會保險量能付費意涵的弱化;雖然,2011年之二代健保改革於財務面不盡理想,但補充保費卻形成了進一步將其他所得納入社會保險課費標準之動力。
The National Health Insurance (NHI) has been implemented over 18 year, and it reached a number of achievements. However, it has been beset by financial crisis, which will be getting more and more serious over time. From the beginning of the National Health Insurance, it encountered great difficulties in financial adjustment and reform. Unfortunately, in the past 10 years, the 2nd generation NHI also suffered the same situation. Until January 2011, in reform of the 2nd generation NHI process, two important ideas were abandoned: Cancellation of all classification among all enrollees and Collecting contribution by household income. This study is to probe into the cause of restrictions of NHI financial adjustment and reform, and these restrictions would contribute to what kind of institutional change. Through the theory of gradual institutional change to explain institutional change modes, and can be summarized in two institutional change modes: before 2011, 2nd generation NHI was not passed, Government did nothing on financial adjustment and reform. We claim that the period is the “drift”. After 2011, 2nd generation NHI had passed, this period called the “layering”. Drift implicates that ability-to-pay principal of taxation of social insurance was eroded. Layering signifies that “Supplementary premiums” would become the momentum of institutional change.