二代健保保費改革方案預評估--民眾與菁英與改革方案之認知與偏好的比較

Abstract

全民健保實施至今已將近十年，儘管民眾滿意度居高不下，但制度本身仍有諸多需要改進之處。為因應層出不窮的健保改革議題，以及建構一個完整的健保體系，因此，政府當局認為應就全民健保進行全面性的檢討與重建，故自2001年9 月至2004 年10 月於行政院下成立「二代健保規劃小組」，大規模進行體制內的健保制度改革。在二代健保規劃小組之下，又大致區分為五組，分別是「政策評估組」、「經濟財務組」、「醫療分配組」、「公民參與組」、與「統計分析組」。本文所欲探討的保費改革方案預評估，即為上述「政策評估組」就「經濟財務組」所提出之保費改革方案，預先進行政治可行性評估。就以往我國社會政策制定過程而言，經常缺乏事先規劃，遑論預評估其可行性。即使預先評估方案之可行性，也多著眼於經濟的可欲性，而缺乏政治的可行性或社會的可接受性之評估。但若僅就經濟面評估方案的可行性，而缺乏事先政治面或社會面的評估，則在推動方案的政治過程中，當面對來自各方的挑戰與質疑時，主事者可能顯得左支右絀、束手無策，連帶影響政策推行的合法性與正當性，2004 年衛生署與健保局主導之「健保雙漲」即為一例。本文主要就政治可行性評估步驟之一，著重於瞭解政策參與者對於保費改革方案之認知與偏好為何，以及探討不同政策利害關係人，尤其是一般民眾與健保菁英，對於議題的看法有無差異，並進而預先提出可能引起爭議之問題，以供方案規劃者或政策制定者參考。根據當時規劃的二代健保保費改革方案的基本原則，作者群分別於2002 年進行一般民眾的電訪調查，並於2003 年進行健保菁英的面訪與訪談。就研究結果來看，一般民眾與健保菁英在於健保知能方面的差距甚大；而在政策偏好方面，一般民眾與健保菁英的看法亦有所差異，例如在醫療費用上漲的財務責任、取消眷屬人數差異的計費方式。但在於設定保費負擔上下限與取消被保險人職業分類方面，則有較高的共識。

The National Health Insurance Program has been implemented for more than 10 years. According to recent statistics, the public satisfaction rates with the Program have often been above 70%. Nevertheless, the NHI Program is not that successful in terms of other aspects. For example, the medical expenses have exceeded the insurance revenues and therefore created huge deficits. Moreover, it is difficult to raise the NHI contribution rate due to political pressures from the Legislative Yuan and the general public. On the face of the aforementioned problems, the Executive Yuan launched a massive re-planning project from 2001 to 2004 (the so called Phase II NHI Program or P2-NHI), which attempted to thoroughly study the problems encountered by the Program and to propose systematic solutions. This paper is based on a pre-evaluation of the P2-NHI financing scheme with special reference to a comparison of the perceptions and preferences of the NHI elites and the general public. This paper begins with a literature review on pre-evaluation and political feasibility analysis as well as an introduction to the new NHI financing scheme. It is followed by an empirical study on the perceptions and preferences of policy stakeholders toward the reform scheme. A comparison of the views of the general public and the elites was drawn on a telephone survey (n1=1,069) and an elites interview (n2=52) with a semi-structured questionnaire. According to research findings, the general public was not so familiar with the NHI issues in comparison with the elites. Moreover, the general public and the elites had different preferences toward certain issues, such as the share of additional medical expenses among stakeholders and the calculation of premiums based on individuals or households. In conclusion, we identified a big gap of NHI literacy between elites and the general public, as well as their consensus and conflicts towards the reform scheme. These findings could be fed back into the policy making process.