二代健保組織體制改革之評析

Review on the Reform of the Organization of the 2nd Generation National Health Insurance Program

李玉君(Yu-Jun Lee)

《臺大法學論叢》 37卷4期 (2008/12) Pp. 1-64

https://doi.org/10.6199/NTULJ.2008.37.04.01

摘要

健保組織體制之定位不僅涉及到整個保險組織結構之設計，同時也因其經營方式的不同，與給付結構、醫療費用支付等息息相關，向為全民健保議題中最難達成共識之問題。現行全民健保組織體制在法制設計上乃一以政府治理為主之模式，此一體制因欠缺實質之社會參與，在衛生署主導下遂有裁判兼球員、權責不相符之弊，再加上單一保險人壟斷保險與醫療服務資源，因而備受爭議。針對現行組織體制之問題，全民健保進行結構性、制度性改革之際，於二代健保規劃中提出了「建構權責相符之全民健保組織體制」兩階段的改革方案。於第一階段中擬將現行監理委員會與費用協定委員會之功能整併，由全民健保監理會掌理之，在第二階段中則將合併健保局及部分衛生署相關單位，成立行政法人全民健保機構，負責政策決定與業務執行。惟此兩階段之改革方案是否果能達到「權責相符」的目標，有進一步檢視之必要。本文即以上述之問題為研究核心，首先概述現行健保組織體制所呈現之問題，繼之釐清二代健保規劃中第一階段與第二階段組織體制改革之內容。進而，以「權責相符」之改革目標檢視、評析二代健保組織體制改革方案，最後，綜納全文之結論並提出個人之建議。

關鍵字

全民健保 ； 組織體制 ； 二代健保 ； 公辦公營 ； 行政法人 ； 權責相符 ； 政府治理 ； 社會參與 ； 社會自治 ； 團體協商

並列摘要

On the one hand, the orientation of the organizational institution of the National Health Insurance (NHI) program is related with the design of the structure; on the other hand, the different patterns it adopted also involve with the structure of the payment and medical expense. Among the issues of NHI, this one has been the most difficult problem to reach consensus. Currently, the NHI legal system was designed mainly as a model controlled by government. Owing to the lack of substantive social participation, it has caused the problem of ”player-umpire” and accountability under the guidance of the Department of Health (DOH). Furthermore, monopolization of insurance and medical service resource of a single-carrier has also made disputes as well.Concerning about the problems of the organizational institution, NHI is scheduling a structural and institutional reform in the Second Generation NHI program- a two-staged reformation proposal of ”establishing an accountable NHI organizational institution”. In the first stage, the Supervisory Board and Negotiation Committee for Medical Expenses will be united and replaced by the NHI Supervisory Committee. In the second stage, the Bureau of NHI and some related units of the BOH will be combined to establish the administrative juristic person of NHI agency in charge of policy decision and administrative implementation. Yet, there are still some questions which require further examination, such as whether the improvement will achieve the goal of accountability, which path people will participate, and the possibility of establishing a competitive system.This study focuses on the above questions, and will start with the issues reflected by the current organizational institution of NHI. Then, we should clarify the contents of the two-staged organizational institution improvement in the Second Generation NHI, and use ”accountability” as a criterion to examine the new program. Eventually, the discussion will bring up suggestions based on arguments concluded.

並列關鍵字

National Health Insurance (NHI) ； organizational institution ； the Second generation NHI ； state management ； executive non-departmental public body/public corporation ； accountability ； governmental governance ； social participation ； social self-governance ； collective negotiation

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