高齡浪潮 – 臺灣長期照顧服務之制度演進與策略思維：從國際比較與管理模式觀點分析

Abstract

面對臺灣快速邁入超高齡社會的人口結構變化，及相應而來日益劇增的失能照護需求，現行長期照顧制度正面臨高度的政策壓力與制度挑戰。臺灣長期照顧制度自2007年之《長期照顧十年計畫》實施以來，歷經1.0至2.0階段，已逐步建立以A/B/C據點為主軸之在地化照顧網絡，擴大涵蓋多元失能群體，並在政策設計與服務供給上取得初步成效。然而，隨著2026年長照計畫2.0即將結束，加上失能人口持續增加與照顧勞動力短缺，現行制度在財政架構、給付邏輯與治理協調層面，皆面臨顯著的結構性限制。如何從現有補助型稅收體系邁向具備韌性與永續性的照顧制度，成為當前臺灣長期照顧政策亟需回應的重要課題。 本研究聚焦於臺灣長期照顧制度的制度架構與政策治理，透過歷史政策分析、國際比較與多元管理工具的應用，檢視其制度邏輯、執行困境與治理挑戰。研究運用多種策略管理分析模組，對現行制度進行多面向診斷，並輔以六個國際代表性國家之長照制度比較，深入借鑑各國在制度建構、財政規劃、服務提供模式及挑戰因應等方面的經驗，探究國際最佳實踐及其在臺灣脈絡下的在地化轉譯可能性。 研究發現，臺灣現行長照制度主要仰賴菸品健康福利捐、菸酒稅、遺產與贈與稅與特別預算等非固定性財源，缺乏穩定且具制度化的保費機制，使得制度長期營運面臨財政不確定風險；給付制度未建構功能性失能分級與彈性給付設計，導致資源分配效率與公平性不足；照顧人力體系則長期處於人力不足、待遇偏低與專業發展不明確之困境；跨部門服務資訊整合亦未健全，影響整體照顧體系的執行力與連續性。整體而言，若我國欲建構一套具備韌性、可近性與永續性的長期照顧體系，其制度核心必須從現行補助導向的稅收制，逐步轉向以社會保險制或混合制為基礎的現代照顧制度架構。 本研究據此提出三項制度演進的核心策略方向。首先，應強化財政結構的穩定性與治理協調機制，透過《長期照顧保險法》之立法與保費制度的導入，確保財政來源具可預測性，並實現跨世代風險共擔的制度邏輯。治理層面應建構中央統籌、地方落實與民間協作的三層次治理體系，提升制度的政策落實力與應變彈性。其次，應推動給付制度的標準化與彈性化，建立科學化的功能性失能評估架構，搭配多元給付模式與差異化自付設計，平衡資源使用效率與照顧公平性；並針對中產家庭設計適度的照顧支出上限制度，以避免資產耗盡風險，提升整體社會的支持度與制度信任。第三，應加速整合照顧人力資源與服務資訊系統，強化照顧服務員的專業認證、職涯制度與待遇改善，並建立照顧管理師制度與跨部門資料共享平台，結合「長照計畫3.0」所倡議之人工智慧輔助照顧與預測功能，以提升服務調度效率與個案照護的連續性。 然而，臺灣長期照顧制度的演進不應止於政策微調或服務擴充，更應視為一場結合系統性改革與價值導向的制度重構工程。唯有在財政穩定、治理協調與服務整合三大面向同步推進，並奠基於社會保險制度的可行演進基礎上，臺灣方能建構一個兼具公平性、制度韌性與永續發展潛能的現代長期照顧體系，進一步實現「全民共享、世代共擔、永續發展」的照顧政策願景。

Amid Taiwan’s rapid demographic shift toward a super-aged society and the accompanying surge in demand for disability care, the existing long-term care (LTC) system is under increasing policy pressure and structural strain. Since the launch of the “Ten-Year Long-Term Care Plan” in 2007, Taiwan’s LTC system has progressed through the 1.0 and 2.0 phases, gradually establishing a community-based service network centered on the A/B/C model, expanding coverage to encompass diverse groups with functional limitations, and achieving initial successes in policy design and service provision. However, with LTC Plan 2.0 nearing its conclusion in 2026, and amid a growing care-dependent population and workforce shortage, the system now faces pronounced challenges in fiscal sustainability, benefit structure, and intergovernmental coordination. Transitioning from a subsidy-driven, tax-based model to a resilient and sustainable care system has become a pressing imperative for LTC policy reform in Taiwan. This study explores the institutional design and policy governance of Taiwan’s LTC system through a multi-method approach combining historical policy review, international comparative analysis, and the application of strategic management frameworks. Multiple diagnostic models are employed to evaluate systemic strengths and limitations, supplemented by case studies from six internationally representative LTC systems from different countries. These cases provide critical insights into institutional configurations, financing strategies, service delivery models, and policy responses, offering a foundation for contextualized adaptation in Taiwan. Findings reveal that Taiwan’s LTC system remains heavily reliant on non-permanent fiscal sources - such as tobacco surcharges, alcohol and tobacco taxes, estate and gift taxes, and special budget appropriations - without a stable, institutionalized insurance premium mechanism. This exposes the system to long-term fiscal uncertainty. The benefit structure lacks a standardized functional needs assessment framework and flexible reimbursement design, resulting in inefficiencies and inequities in resource allocation. The care workforce continues to face chronic shortages, low compensation, and limited professional development, while cross-sectoral data integration remains fragmented, undermining service continuity and governance capacity. To construct a resilient, accessible, and sustainable LTC architecture, Taiwan must progressively transition from its current tax-funded subsidy model toward a social insurance-based or hybrid financing system. Accordingly, this study proposes three strategic directions for institutional evolution. First, enhancing fiscal stability and governance coordination is essential. This includes enacting a “Long-Term Care Insurance Act” and establishing a contributory premium scheme to ensure predictable revenue and institutionalize intergenerational risk-sharing. A tri-level governance framework - comprising central oversight, local execution, and civil sector collaboration - should be developed to reinforce responsiveness and implementation resilience. Second, standardizing and refining the benefit structure is critical. A scientifically grounded functional assessment system, diversified benefit packages, and tiered co-payment mechanisms can improve efficiency and equity. Designing a care expenditure cap for middle-income households can further mitigate asset depletion and strengthen public confidence. Third, integrating care workforce development and information systems is vital. This entails improving professional certification, career pathways, and compensation for care workers, establishing a case management system, and building a cross-sectoral data-sharing platform. These should be aligned with AI-powered care system and predictive models, as proposed in the LTC Plan 3.0, to optimize resource deployment and ensure care continuity. Ultimately, Taiwan’s LTC reform must move beyond incremental policy adjustments or service expansion and instead embrace a comprehensive institutional transformation grounded in long-term vision and social values. Only through the concurrent advancement of fiscal sustainability, coordinated governance, and integrated service infrastructure, anchored in a viable social insurance framework, can Taiwan build a modern LTC system that embodies fairness, institutional resilience, and sustainable capacity, fulfilling the policy vision of “universal coverage, intergenerational solidarity, and long-term sustainability.”