永續的公共體系可能嗎？從全民健康保險探索公民的共同意識

Abstract

背景：隨著人口老化及醫療科技的進步，主要已開發國家建立在政治共同體連帶基礎上的公共健康體系(publicly-funded health system)，過去數十年間無不是在財務危機邊緣擺盪，台灣的全民健康保險政策也是如此。而全國性的調查顯示，多數公民們雖然表達對於全民健康保險的高度支持，但對體系的核心價值判斷卻有很大衝突，例如哪些人應該被納入健保？有限資源應優先給付哪些服務？改進體系是誰的責任？在面對到健保財務危機時，社會在這些問題上必須取得共識，才能夠決定有限資源如何分配、決定共同體成員之間互相負擔的義務到何種程度，使體系得以永續發展。不論西方共和主義傳統、羅爾斯以降的自由主義或公共衛生倫理思想，皆指向某種公民的「共同意識」(sense of the common)是公共體系永續發展的關鍵。然而，在缺乏這樣思想傳統、僅將西方制度加以應用的台灣社會，公民是否具有這種意識尚無缺乏實證資料支持。 目的：初步探索公民如何推論與認同全民健康保險政策的價值基礎，其中是否有某種「共同意識」存在，這種意識與全民健康保險的永續性有何關聯。 方法：本研究採取描述倫理學途徑(descriptive ethics approach)，採典型個案抽樣(typical case sampling)選取受政策影響的一般人(average-like cases)，並輔以年齡、性別、教育程度、工作狀態之配額抽樣選出受訪者進行半結構式面對面深度訪談。訪談大綱預設探索主題包括受訪者對於全民健保政策的整體態度、由國家要求人民負擔互助義務的正當性、健保使用者的構成資格、為促進健保永續經營而同意降低個人福祉的條件、以及參與公共事務的經驗，除此之外隨訪談進行發掘新浮現的主題，並使用主題架構分析法分析訪談資料。研究收案分兩階段，共訪談十七位受訪者，先導研究於2014年四月至五月進行，訪談五位由網路及研究者個人接觸招募之受訪者；第二階段於2014年十一月至2015年一月，訪談十二位由網路招募之受訪者。 結果：儘管對於全民健保體系的認識與規範性價值的判斷上有所不同，大多數受訪者表示對於體系存在的肯定。依據受訪者對於社會互助不同層次的認同、認同的不同理由，以及理解自己與其他共同體成員的連結關係，可區分為「強的共同意識」、「弱的共同意識」以即「沒有共同意識」三者。擁有「強的共同意識」的人存在有對一組核心價值的認同，擁有「弱的共同意識」則能夠支持長期而言有利於其自身的公共體系，二者此共同意識為建構永續健康體系的脈絡因素，前者能夠積極促進體系的永續經營、後者則是體系正常運作的基本條件。從這些理由可以也發現，羅爾斯所假想的那種社會合作前提，應該可以被多數受訪者認可而在有限範圍內進行；而這些理由的歧異性和共同體邊界的模糊性則顯示了，作為健保基礎的政治共同體尚需要被進一步建構。 結論：本研究描繪了從全民健保體系觀點下，共同意識存在的可能樣貌，以及支撐在共同意識背後的社會互助理由，為建構永續健康體系的脈絡因素、以及連帶感概念和政治思想理論提供了實證資料。公共體系的運作需有共同體成員之間的共同意識為基礎，而不只限於利益計算和政治實力的平衡，或訴諸抽象普世的倫理原則。未來健保政策規劃者、改革者，應主動採取措施促進公民的共同意識，並保障充分討論以取得社會共識，如此永續的健保體系才得以可能。

Background: In major developed countries sustainability crisis has haunted their publicly-funded health systems in the past few decades, including Taiwan's National Health Insurance (NHI). National-wide surveys had showed that although Taiwanese citizens support the system on the whole, they hold conflicting judgments among the system's core value, such as the problems of inclusion criteria of the insured, rationale of priority setting, and accountability of performance. Society must meet consensus on how to solve these problems so that limited resources could be legitimately distributed, obligations between community members could be clarified, and public system could been sustainable. Civic republicanism traditions, liberalism since Rawls's account, and public health ethics thoughts all indicate that citizens' sense of the common is the key factor to solve these problems. However, in Taiwan, where the institutions are imported from the West and lack these thought origins, whether citizens have such sense lacks empirical data to support. Objectives: To (1) explore citizens’ reasoning and recognition of the value foundation of the NHI and (2) depict citizens’ sense of the common and explore its relation with sustainability of the NHI. Methods: Using Taiwan's National Health Insurance as a policy case, the research adopted descriptive ethics approach and typical case sampling to select average-like cases. In order to enhance the diversity of social position of participants, quota sampling by age, gender, education and work status were adopted. Researcher conducted semi-structured face-to-face in-depth interview with participants. The interview outline included five a prior themes: (1) interviewee's attitude toward the NHI, (2) legitimacy of compulsory inclusion of the insured, (3) inclusion criteria of the insured, (4) conditions that interviewee would be willing to withhold her/his welfare to maintain the system's sustainability, and (5) interviewee's experiences in any forms of public participation. As the interview progress new themes emerged. Thematic framework analysis was used to analyze the transcription. By the end of the research, 17 participants were interviewed in two stages of recruitment, 5 in the pilot stage started from April 2014 to May 2014 and 12 in the second stage started from November 2014 to January 2015. Results: Despite great difference exists between participants' understanding of the NHI system, most of them recognize the system's core values. According to the recognition of different levels of mutual assistance, the reasons behind them, and the connection between other members of the community, two types of sense of the common could be distinguished. Those with a strong sense of the common recognize a set of core values that uphold the NHI system. Those with a weak sense of common could support the system for their long-term interests via cooperation. These two senses are both the contextual factor for a sustainable healthcare system. The former can actively support the system’s sustainability, while the latter is a necessary condition for maintaining the system’s normal function. These findings suggest that the Rawlsian assumption of social cooperation could be agreed by most of the participants and applied in a limited community. The diversity of the reasons and the vague boundaries of community imply that the moral community where the NHI is grounded might need further construction. Conclusion: Through the case of Taiwan's NHI the research has depicted the possible appearance of the sense of the common, explored the reasons behind it, and provided empirical data to support theories of solidarity and political thoughts. Public system should be founded not on the equilibrium of interest calculation and political power, nor the appeal of abstract universal ethics principles, but the basis of community member’s sense of the common. The NHI policy planners and reformers should adopt measures actively to improve citizens' sense of the common and ensure sufficient debates to meet social consensus so that a sustainable NHI system could be possible.