台灣民眾醫療需求對全民健康保險保費調整支持度之相關性研究：2011年與2021年十年比較分析

Abstract

背景：臺灣自1995年實施全民健康保險以來，已具99.9%以上涵蓋率，提供全民醫療服務。然而在高齡化及少子化造成人口結構改變，以及醫療新科技之發展等因素，導致醫療支出成長快速，而保險收入之成長率卻仍低於支出成長率，健保財務亦面臨收支失衡的壓力。雖政府已採行多元之開源及節流方案，且優先採取調漲保費以外的措施，長期趨勢來看仍有調高費率之需求。惟過往政策經驗顯示保費調漲成面臨政治及民意阻力，導致調整困難，因此有進一步分析我國民眾對於保費調整之態度及相應特徵，以利做為政策規劃之基礎。

目的：為了解台灣民眾對於全民健保保費調漲之情形，以及不同醫療需求與支持保費調漲態度之相關性，歸納研究目的分別檢視2011年及2021年民眾對於調漲健保保費之態度及差異、特徵及醫療需求與保費調整態度之相關性。

方法：本研究採用橫斷面研究設計，利用臺灣社會變遷基本調查2011年及2021年健康相關資料庫進行次級資料分析，並以民眾是否支持健保保費調漲為依變項，以醫療需求（包含具有慢性病情形、自評健康情形、過去1年醫療利用）為主要自變項，並加以控制性別、年齡、教育程度、居住地、家戶所得、健康保險投保情形等人口社會經濟變項。本研究進行以卡方檢定進行兩個年度之描述性統計分析以了解兩個年度間群體特性，並進一步進行雙變項分析，以卡方檢定呈現兩個年度對於健保保費態度及其差異，最後則進行單變項羅吉斯迴歸及多變項羅吉斯迴歸模型，檢驗各因素與保費調整支持度之關聯性。

結果：研究結果顯示，臺灣民眾對健保保費調漲支持度自2011年之49.11%提升至2021年之68.77%，整體支持比例增加接近20個百分點。人口社會經濟特徵中─男性(61.05% vs. 53.98%)、19歲至29歲（63.49%）、高教育程度（64.03% vs. 46.92%）、高所得族群（75.00%）、居住城市（47.35% vs. 18.52%）、具有私人醫療保險者（62.06% vs. 49.60%）─顯著支持保費調漲。在多變項分析亦發現高中學歷以上（AOR=1.603）以上及高所得者(AOR=1.992)支持度相對較高，而女性（AOR=0.792）、30歲至39歲相較更年輕者(AOR=0.699)、居住鄉村者(AOR=0.685)相對不支持保費調漲。在醫療需求因素中，僅「自覺健康狀況」一項具有穩定之相關性，自覺健康不佳者相對不支持保費調漲(AOR=0.824, p=0.009)，而是否具有慢性病、就醫情形及住院情形等醫療需求指標，在多變項羅吉斯模型中未達顯著。本研究最後進行邊際效果分析，2021年相較2011年民眾支持機率增加18個百分點。整體而言，女性相較男性支持機率減少5.1個百分點；相較19至29歲組，30至30歲減少7.9個百分點、50至59歲減少5.5個百分點；有高中學歷以上者增加10.8個百分點；相較於低所得者，隨著收入越高增加更多支持度，4萬元以上未滿8萬元增加7.3個百分點、8萬元以上未滿19萬元組增加8.1個百分點、19萬元以上則增加15個百分點；居住鄉村者減少8.5個百分點；具有私人醫療保險者增加4.8個百分點；自覺健康較差者減少4.3個百分點。

結論：2011年至2021年台灣民眾對於全民健康保險保費調漲態度有顯著提升趨勢，而民眾對於保費調整政策的支持，並非受到客觀健康狀況及實際醫療利用情形所影響而是主觀的自覺健康狀況，自覺健康狀況良好者相對支持保費調漲政策。在人口社會經濟特徵中，相對不支持漲價者為：女性、30歲至39歲、50歲至59歲、高中以下學歷、居住鄉村、無私人醫療保險者。研究亦初步發現當民眾認為社會上多數人願意互相幫助者，更支持保費調漲，可能代表民眾對於社會連帶、風險分擔相關理念的認同，而非僅聚焦自身利益。研究結果建議，未來調升健保費率時，在公共論上除了強調健保財務健全重要性外，亦可強調健保本身風險分擔、互助精神，並提高費率調整頻率，期透過常態化費率調整作為以降低其可能的政治因素；此外，亦應考量相對較無支付能力、醫療資源較不足地區之民眾需求，以提高民眾對保費調升的接受度。

Background: Taiwan’s National Health Insurance (NHI) launched in 1995, provides universal health coverage to near 99.9% of the population in Taiwan. However, aging population, low birth rate, and innovative medical technology have led to rapid growth of healthcare expenditures, also challenge the financial sustainability of the NHI. Although the government has introduced various policies to enhance revenue and implement cost-containment measures, premium adjustment remains necessary in the long term but is often challenged by political and public resistance. Therefore, understanding public attitudes toward premium adjustments is crucial for future policy planning.

Objectives: This study examined changes in public attitudes toward NHI premium between 2011 and 2021 and inquire the feature and the association between healthcare needs and support for premium increases among people in Taiwan.

Methods: A pooled cross-sectional study was conducted using the 2011 and 2021 Taiwan Social Change Survey (TSCS) health modules. The willingness to pay more NHI premium to promote the level of all people’s health was set as the dependent variable. Health care needs, including chronic diseases, self-reported health status, frequency of outpatient visits, hospitalization, and self-paid health examinations, were the main independent variables. Sociodemographic characteristics, including gender, age, education, household income, perceived residential area, and insurances status, were included as covariates. Chi-square tests were conducted for descriptive and bivariate analyses followed by univariate and multivariable logistic regression. Adjusted odds ratios and average marginal effects were estimated.

Results: Supports for higher NHI premium increased from 49.1% in 2011 to 68.8% in 2021, representing an increase nearly 20 percentage points. In the descriptive analysis, men (61.05% vs. 53.98%), younger population aged 19-29 years(63.49%), individuals with higher education years (64.03% vs. 46.92%), higher household income(75.00%), urban residents (47.35% vs. 18.52%), and those with private health insurance(62.06% vs. 49.60%) were significantly more likely to support the premium increases. In logistic regression, higher education years (AOR=1.603) and higher household income (AOR=1.992) were positively associated with support, whereas women (AOR=0.792), aged 30-39 years (AOR = 0.699), rural residents (AOR = 0.685), and poor self-reported health status (AOR = 0.824) were less likely to support premium increases. Among the healthcare need variables, only self-reported health status remained significantly associated with support, while chronic disease, frequency of outpatient visits, hospitalization and self-paid health examinations were not significant. Marginal effect analysis showed that the probability of supporting an NHI premium increase was 18 percentage points higher in 2021 than in 2011. Women (−5.1 percentage points), adults aged 30–39 (−7.9 percentage points) and 50–59 years (−5.5 percentage points), rural residents (−8.5 percentage points), and individuals with poor self-rated health (−4.3 percentage points) were less likely to support a premium increase. In contrast, respondents with at least a senior high school education (+10.8 percentage points), private health insurance (+4.8 percentage points), and higher household income (+7.3 to +15.0 percentage points) were more likely to express support.

Conclusions: Public support for NHI premium increases has increased over the past decade. Support was associated more strongly with socioeconomic characteristics and subjective health perceptions than with objective healthcare needs or healthcare utilization. Preliminary findings also suggest that individuals with stronger beliefs in helping others were more likely to support premium increases, implying that support may reflect recognition of social solidarity and risk sharing rather than purely self-interested considerations. These findings suggest that future premium adjustment policies should emphasize the social insurance values of solidarity and shared responsibility, while also considering affordability and healthcare accessibility for vulnerable populations.