臺灣住宿型長照機構法人化的政策變遷之研究:多元流的研究途徑

Abstract

本研究運用多元流理論之研究途徑，深入探究臺灣住宿型長照機構法人化政策變遷的過程，分析問題流、政策流與政治流如何交互作用並形成制度變革。 在問題流層面，臺灣人口急速老化與長照需求擴增形成制度性壓力，加上私立小型機構頻傳公共安全事故，暴露出個人設立機構在監管、品質及永續經營上的結構性缺陷。1997年《老人福利法》修正開放49床以下小型機構設立，雖有效擴充服務量能，卻衍生財務不透明、人力不足及超收等問題，累積成為改革的深層動因。 政策流的發展呈現漸進式醞釀特徵，法人化構想最初並非行政部門既定方案，而是在立法審查過程中由政治流導入。政府在「營利」與「非營利」、「市場效率」與「弱勢保障」之間不斷權衡，最終採取開放設立營利性質的長照社團法人，但加強監管的折衷方案，並參考醫療法人經驗，提升方案的技術可行性與價值接受度。 政治流則在政策變遷中扮演主導角色，經歷兩波重要衝擊：第一次發生於2013至2015年立法過程，在野黨立委將法人化議題推上議程；第二次於2016年政黨輪替後，既存小型機構串聯發起陳抗，迫使政府調整政策走向。政治流不僅重構問題定義，更牽引政策流的發展方向，最終促成「新舊雙軌並存」的制度安排—新設住宿型長照機構須採法人化、既存機構得依原法令續存。 本研究發現，政策窗呈現動態發展特徵，《長期照顧服務法》第22條規定，創造「結構性（制度性）政策窗」。2016年面臨既存機構強烈反彈，政策窗瀕臨關閉危機，政府透過修法策略重新調整而非直接關閉；政策企業家則在不同階段發揮關鍵作用，如立法委員、行政官員、既存機構業者等。本研究認為，多元流在臺灣政策環境中並非各自獨立發展，而是呈現高度互動關係，其中政治流具有支配性影響力。藉由多元流理論的分析視角，深入理解住宿型長照政策變革過程，為後續相關研究奠定重要基礎，未來研究可進一步探討住宿型長照機構政策的執行成效與長期影響，共同深化對臺灣長照制度轉型的理解。

This study employs the multiple streams framework to explore the policy change process in Taiwan's residential long-term care institutions, analyzing how the problem stream, policy stream, and political stream interact and form institutional transformation. In the problem stream, Taiwan's rapid population aging and expanding long-term care demands create institutional pressure. Combined with frequent public safety incidents in private small-scale institutions, these factors expose structural deficiencies in individually-owned institutions regarding supervision, quality, and sustainable operation. The 1997 amendment to the Elderly Welfare Act allowed the establishment of small-scale institutions with fewer than 49 beds. While this effectively expanded service capacity, it also generated problems such as financial opacity, insufficient staffing, and overcrowding, accumulating as deep-rooted drivers for reform. The policy stream demonstrates characteristics of gradual evolution. The corporatization concept was not initially a predetermined proposal from administrative agencies but was introduced through the political stream during the legislative review process. The government continuously balanced between "for-profit" and "non-profit," "market efficiency" and "protection of vulnerable groups," ultimately adopting a compromise approach that allows the establishment of for-profit long-term care corporate entities while strengthening supervision. Drawing on the experience of medical corporations enhanced the technical feasibility and value acceptability of the proposal. The political stream played a dominant role in policy change, experiencing two significant waves of impact: the first occurred during the legislative process from 2013 to 2015, when opposition legislators pushed the corporatization issue onto the agenda; the second came after the party alternation in 2016, when existing small institutions organized protests, forcing the government to adjust its policy direction. The political stream not only reconstructed problem definition but also guided the development direction of the policy stream, ultimately leading to a "dual-track coexistence" institutional arrangement—newly established residential long-term care institutions must adopt corporatization, while existing institutions may continue operating under original regulations. This study finds that the policy window exhibits dynamic development characteristics. Article 22 of the Long-Term Care Service Act created a "structural (institutional) policy window." In 2016, facing strong resistance from existing institutions, the policy window was on the verge of closing. The government readjusted through legislative amendment strategies rather than direct closure. Policy entrepreneurs played crucial roles at different stages, including legislators, administrative officials, and existing institution operators. This study argues that the multiple streams in Taiwan's policy environment do not develop independently but demonstrate highly interactive relationships, with the political stream having dominant influence. Through the analytical perspective of multiple streams theory, this study provides an in-depth understanding of the residential long-term care policy transformation process, laying an important foundation for subsequent related research. Future studies can further explore the implementation effectiveness and long-term impacts of residential long-term care institution policies, collectively deepening our understanding of Taiwan's long-term care system transformation.