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題名：歷史、制度與政策--臺灣醫療保險體系部份負擔與轉診方案的政策轉折
書刊名：國立臺灣大學社會學刊
作者：林國明
作者(外文)：Lin, Kuo-ming
出版日期：2001
卷期：29
頁次：頁111-184
主題關鍵詞：歷史制度論與新制度論；醫療保險政策；全民健保；部分負擔；轉診制度；Historical institutionalism；New institutionalism；National health insurance；Copayment；Referral systems
原始連結：連回原系統網址new window
相關次數：
  • 被引用次數被引用次數:期刊(13) 博士論文(5) 專書(3) 專書論文(1)
  • 排除自我引用排除自我引用:10
  • 共同引用共同引用:113
  • 點閱點閱:152
臺灣醫療保險體系長期面對的問題之一，是保險病人高額的門診量和擠往大型醫院看診。為了改變這些求診行為造成的「醫療浪費」，政府試圖在1980年代後期引進部分負擔和較診方案，以求抑制不必要的求診行為，提昇資源使用的效率。部分負擔和轉診方案，以求抑制不必要的求診行為，提昇資源使用的效率。部分負擔和轉診方案先後遭到挫敗；前者在增額立委群起反對下無法實施，後者則在施學中心抗拒下胎死腹中。前後失敗的部分負擔，反而解議提高不經較診越級就醫的負擔比率。但這個以加重部分負擔來落實轉診的政策，實施不到一個之後，政府便承認政策失敗，廢除所有有關轉診的規定。
為什麼部分負擔和轉診方案在1980年代會遭受挫敗？為何在全民健保中竟會相互結合，立法成功？為何歷經十年的爭議與規劃的較診政策，竟然只實施了一個月就宣告失敗？本文以?史分析敘事的方式，來解釋這段政策轉折。本文的理論目的在透過這段政策轉折的個案分析，來評價「歷史制度論」(historical institutionalism)這個政策研究取向的分析效用與限制。我們使用「否解點」(veto points)這個概念，來分析並評價政治制度的正式結構對政策解定的影響。我們的分析指出，建構解策場域、次序與行動者關係的正式規則，雖然影響不同行動者介入政策的機會與限制，但難以完整解釋政策解正的後課。認識到這個分析限制，本文主張「將制度脈絡化」，注意到發生在特定解策場域的政策解定所處的環境脈絡，以及解策場域之外的權力關係。本文另一個分析主軸，是在闡明過去的政策所創造出來的制度結構，如何塑造介入政策爭議的行動者的利益、偏好與理念，而影響政治衝突的後果。在這個分析觀點下，本文以為，文化論(cultural approach)所重視的理念對政策決定的作用，以及各種以利益為基礎(interest-based)的政策解釋，必須放在制度的視野中，考察它們如何受到政策的歷史所影響。透過這些觀點，本文主張，要解釋政策決定的複雜動態，我們不但要注意政治行動所座落的制度位置和決策場域外的權力關係的連結，也要分析政策的歷史如何建構政治行動。
This paper examines the history of policy shifts in copayment and referral programs in Taiwan's health insurance systems. With this empirical case, the theoretical goal of this paper is to illuminate the utility and limitations of historical-institutionalist approach in policy analysis. Adopting the analytic concept of "veto point", this paper attempts to evaluate how the formal structures of political institutions affect the outcomes of policy decisions. Our analyses point out that formal rules of decision-making structure, in constituting the locations and sequences of policy decisions and structuring the relations of relevant actors, offer distinctive opportunities and constraints for actors to influence policy decisions, but that formal "rules of the game" cannot fully explain the outcomes of policymaking. With this limitation of formal institutional analysis in mind, this paper urges the necessity of "contexualizing institutions," in that analytic attentions should also be paid to environmental contexts of policy decisions and the power relations outside the arenas of decision-making. Another line of arguments in this paper is to emphasize how the history of past policies shapes the interests, ideas and policy preferences of actors engaging in the political conflicts of policy decisions. With these analytic perspectives, this paper holds that, to capture the complexity and dynamics of policy decisions, we need to analyze not only the linkages of political actions in specific institutional locations and power relations outside the arenas of decision-making, but also how the history of past polices constitute political actions in conflict.
期刊論文
1.林國明(20000500)。全民健保民營化的政治邏輯。臺大社會工作學刊，2，55+57-96。new window  延伸查詢new window
2.Yee, Albert S.(1996)。The Causal Effects of Ideas on Policies。International Organization，50(1)，69-108。  new window
3.費景漢、黃耀輝(19941200)。全民健保法通過後之省思。保險專刊，38，1-15。new window  延伸查詢new window
4.Campbell, John L.(1998)。Institutional Analysis and the Role of Ideas in Political Economy。Theory and Society，27，377-409。  new window
5.Manning, W. G.(1987)。Health Insurance and the Demand for Medical Care。American Economic Review，77(3)，251-277。  new window
6.Pauly, Mark V.(1978)。The Economics of Moral Hazard: Comment。American Economic Review，58。  new window
7.Pfaff, Martin(1990)。Differences in Health Care Spending Across Countries: Statistical Evidence。Journal of Health Politics, Policy and Law，15，1-24。  new window
8.Skocpol, Theda、Amenta, Edwin(1986)。States and Social Policies。Annual Review of Sociology，12(1)，131-157。  new window
9.Steinmo, Sven、Watts, Jon(1995)。It's the Institutions, Stupid! Why Comprehensive National Health Insurance Always Fails in America。Health Politics, Policy and Law，20(2)，330-372。  new window
10.林國明(19971200)。國家與醫療專業權力：臺灣醫療保險體系費用支付制度的社會學分析。臺灣社會學研究，1，77-136。new window  延伸查詢new window
11.Evans, Robert G.(1987)。Hang Together, or Hang Separately: The Viability of a Universal Health Care System in an Aging Society。Canadian Public Policy，13(2)，165-180。  new window
12.Finnemore, Martha(1996)。Norms, Culture, and World Politics: Insights from Sociology's Institutionalism。International Organization，50(2)，325-347。  new window
13.Ikenberry, G. John(1988)。Conclusion: An Institutional Approach to American Foreign Economy Policy。International Organization，42，219-243。  new window
14.Sokolovsky, Joan(1998)。The Making of National Health Insurance in Britain and Canada: Institutional Analysis and Its Limits。Journal of Historical Sociology，11(2)，247-280。  new window
15.Weaver, R. Kent(198610)。The Politics of Blame Avoidance。Journal of Public Policy，6，371-398。  new window
16.Skocpol, T.(1995)。Why I Am an Historical Institutionalist。Polity，28(1)，103-106。  new window
17.張苙雲(19981000)。「逛醫師」的邏輯：求醫歷程的分析。臺灣社會學刊，21，59-87。new window  延伸查詢new window
18.張苙雲、謝幸燕(19940200)。就醫流向的長期變遷。中華公共衛生雜誌，13(1)，54-76。new window  延伸查詢new window
19.Hall, Peter A.、Taylor, Rosemary C. R.(1996)。Political Science and the Three New Institutionalisms。Political Studies，44(5)，936-957。  new window
20.Immergut, Ellen M.(1998)。The Theoretical Core of the New Institutionalism。Politics & Society，26(1)，5-34。  new window
21.張苙雲(19980100)。從不穩定的口碑到主要的求醫場所：臺灣西醫的制度信任建構。國家科學委員會研究彙刊. 人文及社會科學，8(1)，161-183。  延伸查詢new window
會議論文
1.林佳龍(1994)。外來政權、反對運動與地方派系的選舉互動：論國民黨提名政策的演變與台灣的民主化。台灣政治學會第一屆年會：邁向台灣政治學，(會議日期: 12月17-18日)。台北。  延伸查詢new window
研究報告
1.行政院衛生署(1990)。醫療保健計畫--建立全國醫療網第二期計畫。臺北：行政院衛生署。  延伸查詢new window
2.張鴻仁(1990)。全民健保醫療費用支付制度之研究。台北。  延伸查詢new window
學位論文
1.林國明(1997)。From Authoritarianism to Statism: The Politics of National Health Insurance in Taiwan(博士論文)。Department of Sociology，New Haven, CT。  new window
圖書
1.Pierson, Paul(1995)。Dismantling the Welfare State? Reagan, Thatcher, and the Politics of Retrenchment。Cambridge University Press。  new window
2.Orloff, Ann Shola(1993)。The Politics of Pensions: A Comparative Analysis of Britain, Canada, and the United States, 1880-1940。Madison, WI：The University of Wisconsin Press。  new window
3.行政院衛生署(1986)。醫療保健計畫--籌建醫療網計畫。臺北：行政院衛生署。  延伸查詢new window
4.立法院秘書處(1994)。全民健康保險法。台北：立法院。  延伸查詢new window
5.全民健康保險規劃小組(1990)。全民健康保險制度規劃技術報告。台北：行政院經建會。  延伸查詢new window
6.立法院秘書處(1988)。勞工保險條例修正案。台北：立法院。  延伸查詢new window
7.石曜堂(1992)。「國民醫療保健支出調查」初步分析報告。台北：行政院衛生署。  延伸查詢new window
8.藍忠孚(1990)。籌建台灣地區醫療網實施績效之評估研究。台北：行政院衛生署。  延伸查詢new window
9.楊志良、吳淑瓊(1983)。台灣地區勞工保險門診醫療費用及疾病結構之研究。台北：勞保局。  延伸查詢new window
10.Abel-Smith, B.(1984)。Cost Containment in Health Care。London：Bedford Square Press。  new window
11.Abel-Smith, B.(1992)。Cost Containment and New Priorities in Health Care。Brookfield, Vermont：Avebury。  new window
12.Alford, Robert R.(1975)。Health Care Politics: Ideological and Interest Group Barriers to Reform。Chicago：University of Chicago Press。  new window
13.Barer, Morris L.、Evans, Robert G.、Stoddart, Glen L.(1979)。Controlling Health Care Costs by Direct Charges to Patients: Snare or Delusion?。Toronto：Ontario Economic Council。  new window
14.Finefold, Kenneth、Skocpol, Theda(1995)。State and Party in America's New Deal。Madison, Wisconsin：The University of Wisconsin Press。  new window
15.Greenberg, W.(1987)。Competition in the Health Care Sector: Past, Present, and Future。Germantown, MD：Aspen Systems Corp.。  new window
16.Reagan, M. D.(1992)。Curing The Crisis: Options For America's Health Care。Boulder：Westview Press。  new window
17.Skocpol, Theda(1996)。Boomerang: Clinton's Health Security Effort and The Turn Against Government in U.S. Politics。W.W. Norton。  new window
18.Weir, Margaret(1992)。Politics and Jobs: The Boundaries of Employment Policy in the United States。Princeton, NJ：Princeton University Press。  new window
19.全民健康保險規劃小組(1990)。國人對全民健康保險的認知、參與暨負擔意願。台北：行政院經建會。  延伸查詢new window
20.Anderson, Odin W.(1989)。The Health Services Continuum in Democratic States: An Inquiry into Solvable Problems。Ann Arbor, Michigan：Health Administration Press。  new window
21.Glaser, William A.(1991)。Health Insurance in Practice。San Francisco：Jossey-Bass。  new window
22.Hall, Peter A.(1986)。Governing the Economy: The Politics of State Intervention in Britain and France。New York：Oxford University Press。  new window
23.Heclo, Hugh(1974)。Modern social politics in Britain and Sweden: From relief to income maintenance。New Haven, CT：Yale University Press。  new window
24.Navarro, Vicente(1994)。The Politics of Health Policy: The U.S. Reforms, 1980-1995。Cambridge：Blackwell。  new window
25.Skocpol, Theda(1995)。Social Policy in the United States: Future Possibilities in Historical Perspective。Princeton, NJ：Princeton University Press。  new window
26.Steinmo, Sven、Thelen, Kathleen Ann、Longstreth, Frank(1992)。Structuring Politics: Historical Institutionalism in Comparative Analysis。Cambridge：Cambridge University Press。  new window
27.North, Douglass C.(1990)。Institutions, Institutional Change and Economic Performance。Cambridge, MA：Harvard University Press。  new window
28.Immergut, Ellen M.(1992)。Health Politics: Interests and Institutions in Western Europe。Cambridge University press。  new window
29.Skocpol, Theda(1992)。Protecting Soldiers and Mothers: The Political Origins of Social Policy in the United States。The Belknap Press of Harvard University Press。  new window
30.Olson, Mancur Jr.(1965)。The logic of collective action: Public goods and the theory of groups。Harvard University Press。  new window
圖書論文
1.Weir, Margaret、Skocpol, Theda(1985)。State Structures and the Possibilities for "Keynesian" Responses to the Great Depression in the United States。Bringing the State Back in。New York：Cambridge University Press。  new window
2.Weir, Margaret、Orloff, Ann Shola、Skocpol, Theda(1986)。Understanding American Social Politics。The Politics of Social Policy in the United States。Princeton, NJ：Princeton University Press。  new window
3.林國明(2000)。民主化的侷限與社會政策的公共參與：以全民健保為例。台灣的社會福利運動。台北：巨流圖書公司。  延伸查詢new window
4.張苙雲(1998)。健康與醫療。社會學與台灣社會。台北：巨流圖書公司。  延伸查詢new window
5.Dohler, M.(1989)。Physicians' Professional Autonomy in the Welfare State: Endangered or Preserved?。Controlling Medical Professionals: The Comparative Politics of Health Governance。Newbury Park, CA：Sage Publications。  new window
6.Goldstein, Judith、Keohane, Robert O.(1993)。[Ideas and Foreign Policy: Beliefs, Institutions, and Political Change] Introduction。Ideas and Foreign Policy: Beliefs, Institutions, and Political Change。Ithaca, NY：Cornell University Press。  new window
7.Kuitzin, Joseph(1998)。The Appropriate Role for Patient Cost Sharing。Critical Challenges for Health Reform in Europe。  new window
8.Migdal, Joel S.(1997)。Studying the State。Comparative Politics: Rationality, Culture, and Structure。New York, NY：Cambridge University Press。  new window
9.Newhouse, Joseph P.(1987)。The Structure of Health Insurance and the Erosion of Competition in the Medical Marketplace。Competition in the Health Sector: Past, Present, and Future。Germantown, MD：Aspen Systems Corp.。  new window
10.Weir, Margaret(1992)。Ideas and the Politics of Bounded Innovation。Structuring Politics: Historical Institutionalism in Comparative Analysis。New York：Cambridge University Press。  new window
11.林國明、蕭新煌(2000)。台灣的社會福利運動導論：理論與實踐。台灣的社會福利運動。台北：巨流。new window  延伸查詢new window
12.Katznelson, Ira(1997)。Structure and Configuration in Comparative Politics。Comparative politics: rationality, culture, and structure。New York：Cambridge：Cambridge University Press。  new window
13.Immergut, Ellen M.(1992)。The Rules of the Game: The Logic of Health Policy-Making in France, Switzerland, and Sweden。Structuring Politics: Historical Institutionalism in Comparative Analysis。New York：Cambridge University Press。  new window
14.Thelen, Kathleen、Steinmo, Sven(1992)。Historical Institutionalism in Comparative Politics。Structuring Politics: Historical Institutionalism in Comparative Analysis。Cambridge University Press。  new window
 
 
 
 
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