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題名 | 歷史、制度與政策--臺灣醫療保險體系部份負擔與轉診方案的政策轉折=History, Institutions, and Policy: Policy Shifts of Copayment and Referral Programs in Taiwan's Health Insurance Systems |
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作者 | 林國明; | 書刊名 | 國立臺灣大學社會學刊 |
卷期 | 29 2001.02[民90.02] |
頁次 | 頁111-184 |
分類號 | 412.56 |
關鍵詞 | 歷史制度論與新制度論; 醫療保險政策; 全民健保; 部分負擔; 轉診制度; Historical institutionalism; New institutionalism; National health insurance; Copayment; Referral systems; |
語文 | 中文(Chinese) |
中文摘要 | 臺灣醫療保險體系長期面對的問題之一,是保險病人高額的門診量和擠往大型醫院看診。為了改變這些求診行為造成的「醫療浪費」,政府試圖在1980年代後期引進部分負擔和較診方案,以求抑制不必要的求診行為,提昇資源使用的效率。部分負擔和轉診方案,以求抑制不必要的求診行為,提昇資源使用的效率。部分負擔和轉診方案先後遭到挫敗;前者在增額立委群起反對下無法實施,後者則在施學中心抗拒下胎死腹中。前後失敗的部分負擔,反而解議提高不經較診越級就醫的負擔比率。但這個以加重部分負擔來落實轉診的政策,實施不到一個之後,政府便承認政策失敗,廢除所有有關轉診的規定。 為什麼部分負擔和轉診方案在1980年代會遭受挫敗?為何在全民健保中竟會相互結合,立法成功?為何歷經十年的爭議與規劃的較診政策,竟然只實施了一個月就宣告失敗?本文以?史分析敘事的方式,來解釋這段政策轉折。本文的理論目的在透過這段政策轉折的個案分析,來評價「歷史制度論」(historical institutionalism)這個政策研究取向的分析效用與限制。我們使用「否解點」(veto points)這個概念,來分析並評價政治制度的正式結構對政策解定的影響。我們的分析指出,建構解策場域、次序與行動者關係的正式規則,雖然影響不同行動者介入政策的機會與限制,但難以完整解釋政策解正的後課。認識到這個分析限制,本文主張「將制度脈絡化」,注意到發生在特定解策場域的政策解定所處的環境脈絡,以及解策場域之外的權力關係。本文另一個分析主軸,是在闡明過去的政策所創造出來的制度結構,如何塑造介入政策爭議的行動者的利益、偏好與理念,而影響政治衝突的後果。在這個分析觀點下,本文以為,文化論(cultural approach)所重視的理念對政策決定的作用,以及各種以利益為基礎(interest-based)的政策解釋,必須放在制度的視野中,考察它們如何受到政策的歷史所影響。透過這些觀點,本文主張,要解釋政策決定的複雜動態,我們不但要注意政治行動所座落的制度位置和決策場域外的權力關係的連結,也要分析政策的歷史如何建構政治行動。 |
英文摘要 | This paper examines the history of policy shifts in copayment and referral programs in Taiwan's health insurance systems. With this empirical case, the theoretical goal of this paper is to illuminate the utility and limitations of historical-institutionalist approach in policy analysis. Adopting the analytic concept of "veto point", this paper attempts to evaluate how the formal structures of political institutions affect the outcomes of policy decisions. Our analyses point out that formal rules of decision-making structure, in constituting the locations and sequences of policy decisions and structuring the relations of relevant actors, offer distinctive opportunities and constraints for actors to influence policy decisions, but that formal "rules of the game" cannot fully explain the outcomes of policymaking. With this limitation of formal institutional analysis in mind, this paper urges the necessity of "contexualizing institutions," in that analytic attentions should also be paid to environmental contexts of policy decisions and the power relations outside the arenas of decision-making. Another line of arguments in this paper is to emphasize how the history of past policies shapes the interests, ideas and policy preferences of actors engaging in the political conflicts of policy decisions. With these analytic perspectives, this paper holds that, to capture the complexity and dynamics of policy decisions, we need to analyze not only the linkages of political actions in specific institutional locations and power relations outside the arenas of decision-making, but also how the history of past polices constitute political actions in conflict. |
本系統之摘要資訊系依該期刊論文摘要之資訊為主。