中共醫療改革的制度分析

Abstract

社會福利的成長速度超過了一般資本主義國家的財政負擔，幾乎可以說是各國財政的夢魘。因此各國莫不企求能在不增加財政支出的原則下，調整政府組織或是者是政策執行架構，以達到一方面節約成本，另方面又能繼續施政的雙贏。因此這種原本是以因應社會福利政策高支出的辦法－成立「基金」就被許多國家重新思考與引用。\n這種以「基金國家」為主體的管理與施政方式同時涉及了幾方面治理模式的改變：（一）在財政上與政府預算脫鉤；（二）政府與基金的地位在法律上相對平行，同時也由上下隸屬關係成為平行契約關係；（三）政府必須在原有的政府組織之外另設管理與獨立監督機構以進行監督與管理；（四）與政府的關係是建立在法律關係上，同時基金也享有公法人之地位，基金一切營運管理必須依照法律規定進行。這種維持「一個手臂」距離的治理方式的最大優點就是少了政府官僚組織僵化的問題，同時又能適度引進市場機制的競爭，以維持效率與效能。\n中國的醫療保障制度自八○年代後展開了一連串的改革，到了九二年的「兩江模式」試點可以說是到了一個新的轉折點。改革之後的中國醫療體制度由於法令的不夠週延，卻使各地方的醫療保障基金各據山頭，成為各地方政府的小金庫。雖然如此，但是「基金國家」的雛形卻是已經出現，這是否是未來中國的一種新的治理模式，值得各界觀察。

The rapid growth of social welfare has worsened financial difficulties of capitalist countries in general, so whatever principle that may help assure the realization of related polices without increasing fiscal expenditures becomes desirable. Thus the managerial pattern based on funds has been widely taken into account and adopted.\nThe features of such “fund-states” pattern are as follows. First, the funds are fiscally independent of governmental budgets. Second, legally the government and the funds are relatively equal. Third, the funds must be under management and supervision of independent agencies established by the government. Fourth, while the funds are given a status of public corporation, its relationship with the government is based on laws. Such managerial pattern “one arm-swinging distance” can mostly benefit from the market competitive system properly introduced to maintain efficiency and effectiveness.\nIn China, the problem of medicare funds is hard to solve due to the incompletion of laws. Nevertheless, the “fund-states” pattern has come into bud. Whether it will emerge as a brand-new managerial pattern of China is worth more observation.\n\nKeywords:\ngovernance；public management；market economics；medical reform；fund-states