柯林頓政府醫療改革推行之研究

The Analysis of U.S. Clinton Administration’s Health Care Reform

林郁芬(Yu-Fen Lin)

指導教授 ： 李本京

淡江大學/國際研究學院/美國研究所碩士班/碩士(2009年)

https://doi.org/10.6846/TKU.2009.00230

摘要

本論文之研究主旨在探討美國柯林頓政府任內改革健保制度並試圖推行全民健保所作探討的策略。一九九○年代初，健保費用高漲及保險給付降低，造成失去保險的人數不斷增加，健保成本攀升造成政府赤字不斷膨脹，在此背景之下，逐漸演變成為要求健保改革之運
動。柯林頓甫上任便兌現其競選承諾，指派希拉蕊主導健保改革之策劃，目標在於使全民皆享有健康保險及減輕政府財政之負擔。在當時民主黨掌握白宮及國會雙重優勢情況下，本有機會通過其所支持之法案，然於推行過程中，未能多方徵詢各方意見，加上反對聲浪頗大，因而此立意良善之計劃，最後仍功虧一簣，未能成為法律。而健保計劃推行的失敗，亦間接造成民主黨一九九四年國會期中選舉的挫敗，讓出了參眾兩院多數黨的位置。
經分析其提案內容及推行過程，可看出：其一，未能與反對黨針對健保計劃進行有效之協商，同黨議員亦缺乏共識；其二，多數利益團體被排除參與計畫工作小組 (task force)，深怕既有利益被剝奪，反而形成一股強大的反對力量；其三，柯林頓高估了其政治實力
，並且未趁勝選掌握提案最佳時機，經濟復甦更降低民眾健保改革之需求：其四，計畫內容缺乏簡單易懂之目標，並且未經多方辯論，難以說服美國人接受這一套計劃；其五，政府過度干預健保市場，容易被批評成大政府 (big government)，並且與美國人崇尚個人主義
及自由放任思想有所牴觸。種種情勢之誤判，交互影響造成此一提案之挫敗。
因此本論文內容，於第一章說明研究動機、目的、限制與範圍；第二章則簡述美國至九○年代止社會福利發展之沿革，並敘述各總統任內有哪些主要健保措施；第三章則針對柯林頓政府當時提案之背景、健保計劃之內容及施行策略、以及提案之後所引發的反對聲
浪及期中選舉失敗陳述；第四章則主要分析健保改革計劃挫敗之因素，及所面臨的困境為何。第五章為結論，歸納前述章節所述，敘述後代有意改革美國健保制度者可從中獲得何種教訓，避免重蹈覆轍。

關鍵字

柯林頓 ； 希拉蕊 ； 健保 ； 社會福利 ； 管理式競爭 ； 健康維護組織

並列摘要

The purpose of this thesis is to analyze the U.S. Clinton administration’s health care reform and the attempt to have the universal coverage of health insurance in the U.S. In 1990s, the escalating health care costs and declining coverage was mainly the outcome of an increasing number of uninsured Americans. The rising health care cost had helped a prolonged swell of the deficit. These problems led to a powerful movement requesting health care reform. Clinton, when took office, fulfilled his campaign promise by appointing the First Lady Hillary Clinton to chair the task force on national health care reform with the aim of having universal coverage of health insurance and reducing the heavy financial burden on government. Being a Democratic President having a Democratic majority in the Congress, Clinton could have stood on a vantage point to pass the Health Security Act he advocated. Nevertheless, the proposal fell short of success due to a combination of factors (e.g. failing to include varied opinion, the rising objection and doubtfulness to the proposal itself), which further frustrated the Democrats in 1994 congressional election and the Republican Party regained a majority of seats in the House and Senate since 1954.
By investigating the proposal and process of approval, it is clear that the following factors should share the responsibility for the failure of Health Security Act. First of all, Clinton failed to negotiate with the opposition party in terms of the content and even Democrats lacked for consensus in Capitol. Secondly, lots of interest groups were not taken into account in the task force and instead started to advocate against the proposal and to criticize it with the fear of losing the vested interests. Third, Clinton misjudged his political strength and failed to recognize the limit of his authority and missed the best time to propose the Health Security Act. Economic improvement also slowed the momentum for health care reform. Fourth, it may not be easy for Americans to take a plan without core principles and had not been debated in public. What’s more, the proposal was criticized about its interference in the health insurance market to an extent of big government, which contradicted the thinking of individualism and laissez-faire in the U.S. These factors led to the defeat of the proposal in 1994.
In this thesis, chapter one is the introduction including the motivation, purpose and framework of this study. Chapter two discusses the brief history of social welfare system in the U.S. and previous policies on health care. Chapter three analyzes the background, target, content of Clinton’s proposal and the reaction after it was proposed. Chapter four mainly focuses on the reasons that cause the defeat of Clinton’s health care reform. Chapter five is the conclusion.

並列關鍵字

Clinton ； Hillary ； health care ； social welfare ； managed competition ； Health Maintenance Organization

參考文獻

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