2021年全民健康保險費率調整之政策過程：多元流觀點之分析

Abstract

全民健康保險（以下簡稱健保）費率歷次調漲，政治成本均極為沉重，曾造成首長於費率調漲後去職。然而2021年衛福部長陳時中將一般保險費率回升至5.17%，卻未引發政治風暴而致其去職。此一與過往不同的政治現象，構成本研究的核心問題意識，在制度、行動者與外部環境是否有結構性之不同。過往文獻卻較少從制度設計、流程安排與政策議程設定之角度，剖析其背後結構性原因。本研究以Kingdon所提出之多元流理論為主要分析架構，採取質性研究方法，結合深度訪談、健保會會議紀錄與政府公報、媒體與輿論分析等，透過交叉比對試圖重建2021年費率調整政策窗開啟、匯流與政策成功推行的完整圖像。 在問題流層面，三項長期結構性問題已達臨界點。首先，台灣人口快速老化，同時工作年齡人口於2015年達到高峰後遞減，使健保費基萎縮且財務負擔加重。長者使用健保醫療費用佔比逐漸加重，顯示醫療資源分配與世代負擔失衡。第三，新藥與新科技引進使醫療支出逐年攀升。此外，健保自2017年起連年呈現財務短絀，安全準備金逼近法定下限。 在政策流層面，除調漲保費費率此最直接挹注之方案外，亦有多項替代方案的討論，其中最重要且爭議最激烈的議題為要求政府補足積欠法定36%總經費負擔之差額。健保會付費者代表質疑計算公式錯誤與部分社會福利項目納入政府負擔經費之計算基礎，使政府實質短付應負擔之總經費。費率方案部分，健保會將付費者代表主張最低幅度維持財務平衡之費率4.97%甲案及醫界代表強調財務穩定與制度精神之費率5.47 – 5.52 %乙案，以「兩案並陳」方式由衛福部呈行政院進行核定。 在政治流面向，費率調整深受社會氛圍、媒體輿論、利益團體角力與行政高層意向等因素影響。政府透過媒體釋放風向球偵測社會輿論，且COVID-19防疫成功累積高民意支持與首長威信，成功抵銷漲價的政治壓力。健保會發揮多方協商與責任分散功能，有效化解付費者團體針對政府負擔36%爭議的杯葛，使費率議程得以依既定時程推進。在費率幅度的最終抉擇上，政府以「還原」而非「調漲」的修辭框架降低民眾排斥，並在疫情期間兼顧社會衝擊最小化與健保財務永續間之平衡。 政策窗在2020年間由「安全準備金跌破法定下限的預期」（法律規範、問題窗）、「疫情帶給民眾醫療與健康風險的感知」（社會氛圍、政治窗）與「總統高票連任、距離下次大型選舉較遠」（政治氛圍、政治窗）三者共同打開，讓費率調整方案得以送上決策議程。同時陳時中部長發揮政策企業家功能，將費率「回復」到5.17%的敘事，化解阻力並降低可能的政治風暴，未付出重大政治代價下完成費率調漲。 2021年費率順利調漲且首長未因而去職，實為偶然的政治契機與具參考價值的策略制度所共同促成。特定時空的外部危機與選舉週期中的獨特性，屬難以再現的偶然。COVID-19疫情使民眾對醫療的重視超過對漲價的厭惡，防疫成功帶來社會信任顯著降低政治阻力。當時正值總統連任後的高聲望期，且距離下次大選尚遠，提供政治緩衝空間。可複製的策略典範部分，決策者透過法律規範將財務調整轉化為行政義務，善用客觀指標與法定協商平台分散決策壓力，具備高信任度的政策企業家利用修辭框架化解阻力。此次成功雖受惠於疫情時政治窗的偶然開啟，但真正的價值在於能將經驗加以制度化，減少對個別決策者勇氣或極端危機的依賴。 本研究於理論層面提出兩項延伸觀點。其一，論證收支連動機制、健保會協商平台及法定審議程序，共同構成了具約束力且能分散責任的治理架構。此架構將高度敏感的財務決策納入常規化程序，有效減輕政策制定對個別首長政治勇氣的過度依賴。其二，引用「位移效果」（Displacement Effect）概念，説明全球性公共衛生危機如何在政治流中創造強大的政策窗，降低民眾對加稅或漲價政策的抵抗。 總結而言，2021年健保費率調整不僅是單一政策事件，更標誌著台灣健保制度的調整由個人政治承擔邁向制度性決策的轉折。期盼本研究能為未來健保財務改革以及更廣泛之社會保險政策研究，提供具參考價值的理論框架與實務啟示。

Historically, the political cost of raising National Health Insurance (NHI) premiums has been immense, even forcing the resignation of former ministers. Conversely, the 2021 adjustment of premium rate was executed with relative political tranquility. Despite the inherent sensitivity of the policy, Minister Chen Shih-chung successfully restored the rate to 5.17% without triggering a political backlash or jeopardizing his portfolio. This political phenomenon constitutes the core research question of this study: whether the 2021 premium rate adjustment exhibited structural differences compared to past ones. This study investigates the structural changes in institutions, actors, and the external environment that allowed for this relatively smooth transition. Utilizing Kingdon’s Multiple Streams Framework (MSF), this qualitative research reconstructs the opening of the policy window in 2021 through in-depth interviews, NHI Committee (NHIC) meeting minutes, official government gazettes, and media sentiment analysis. In the problem stream, three issues reached a breaking point by 2020. First, Taiwan is aging rapidly and the working-age population declined since 2015, eroding the base of premium. Second, a generational imbalance in resource allocation has emerged. Third, “medical inflation” driven by the adoption of new health technologies and high-cost drugs has consistently outpaced the general inflation. Furthermore, NHI safety reserves approached the statutory minimum after consecutive years of deficits since 2017. In the policy stream, although raising premium rates represented the most direct fiscal solution, alternative measures ignited significant argument. The most significant dispute was the demand by payer representatives for the government to fulfill its statutory obligation to subsidize at least 36% of the NHI’s total expenditures. Payers argued that the government had manipulated calculation formulas and inappropriately included social welfare items in the NHI budget, resulting in a substantial underpayment. They contended that bridging this gap would prevent the need for a rate hike. To bypass this deadlock, the NHIC ultimately adopted a “dual proposal” for the final decision of the Executive Yuan. In the political stream, the NHI premium rate adjustments were shaped by intricate interplay of social atmosphere, media opinion, interest group dynamics, and the strategic intent of senior administration officials. The government utilized media trial balloons to gauge public sentiment, subsequently leveraging the high public approval and ministerial prestige accumulated through successful COVID-19 containment to offset the political pressure of the rate hike. The NHIC functioned as a platform for multi-stakeholder deliberation and diffusing decision-making responsibility, effectively neutralizing attempts to block the rate adjustment over the disputed 36% government contribution. As for the final determination of the adjustment magnitude, the government employed a rhetorical framing of "restoration" rather than an "increase" to minimize public resistance. By accounting for the payment capacity of both enterprises and individuals during the pandemic, the administration successfully achieved an equilibrium between minimizing social impact and ensuring financial sustainability of the NHI. The Policy Window opened in 2020 through the convergence of legal necessity (safety reserves falling below the legislative limit), social perception of health risks (pandemic anxiety), and the political cycle (post-election honeymoon period). Minister Chen acted as a policy entrepreneur, framing the adjustment as a "restoration" which successfully neutralized resistance. The successful premium adjustment without subsequent ministerial resignation resulted from a combination of unplanned political opportunities and replicable strategic institutions. The COVID-19 pandemic caused the public to prioritize healthcare resilience over resistance to premium increases. The social trust generated by successful epidemic control significantly lowered political resistance. The high approval following the president's reelection and the distance from the next major election provided a crucial political buffer. About reproducible strategic paradigms, decision-makers transformed financial adjustments into administrative obligations through legal norms, utilized objective indicators and statutory deliberative platforms to diffuse decision-making pressure, and employed a highly-trusted policy entrepreneur to neutralize resistance through precise rhetorical framing. The ultimate value lies in the institutionalization of these experiences. Establishing a systematic mechanism can reduce reliance on individual political courage officials or external crises. At the theoretical level, this study offers two perspectives. First, it argues that the revenue-expenditure linkage mechanism, the NHIC deliberative platform, and statutory review procedures together constitute a binding governance framework capable of diffusing responsibility. This framework embeds politically sensitive financial decisions within routinized procedures, thereby substantially reducing over-reliance on the political courage of individual ministers. Second, it draws on the concept of the “Displacement Effect” to explain how a global public health crisis can generate a powerful policy window, lowering public resistance to tax or premium increases. In conclusion, the 2021 premium adjustment represents a paradigmatic shift from the reliance on individual political sacrifice toward a model of institutionalized, rule-based decision-making. This study aims to provide a valuable theoretical framework and practical insights for future NHI financial reform and social insurance policy studies.