從美國經驗探討台灣長期照護制度改革

An exploration of long-term care policy reform in Taiwan: what can we learn from the U.S. experience

本文探討美國長期照護制度及近年長期照護政策改革方案，期望能借鏡美國經驗，提供我國發展長照政策之參考。綜觀美國近年長照改革，除強化機構服務品質外，並持續發展個人化、家庭化、及社區化的長照服務，鼓勵家庭照顧者成為長照體系的一環，建立在地化的服務輸送體系。美國長照政策改革失敗之主因繫於長照財務，1988年老年醫療保險擴張改革，因保費調漲及稅負分配問題引發反彈，而2010年隨醫改通過的社區居住照護法案，雖欲建立自願投保的公共保險，卻無法確保清償能力下仍能維持可負擔的低廉保費。借鏡美國經驗，我們認為長照2.0以發展居家照護與社區照護為主，政府應重視家庭成員提供失能者無償照顧背後隱含的龐大社會成本，考慮讓家庭成員成為長照產業供給人力，實施現金給付政策並提供完善喘息服務。此外，家庭化及社區化的長照服務可能易因地區收入間的差異，而導致服務品質落差。未來政策應強化照顧者專業能力，及確保照護品質的地域平等性。最後，待長照服務體系建置完善及照顧人力充足後，實施具互助精神且財源相對穩定之長期照護保險是政府可以思考的選項。參考美國改革之例，若日後實施長照社會保險，為避免嚴重之逆選擇問題，建議採強制納保，以維持保險制度之永續經營。

The main purpose of this paper is to investigate the long-term care system and recent longterm care policy reforms in the United States (U.S.). Overall, recent policy reforms in the U.S. have focused on improving the quality of institutional care while pushing for more development in personalized in-home and community care. Previous attempts at major reforms in long-term care failed mostly because of issues in financing them. In 1988, the expansion of Medicare and Medicaid coverage and eligibility were quickly overturned due to concerns about rising costs and unequal contributions from taxpayers. Recently, the Community Living Assistance Services and Supports Act (The CLASS Act) was enacted as part of the Patient Protection and Affordable Care Act. The CLASS Act would have established a voluntary national public insurance program for long-term care, but its design prevented the Act from satisfying the requirement to be actuarially sound while keeping the insurance premiums affordable. Learning from the U.S. experience, we suggest that the government should take into account the social costs associated with uncompensated care provided by family members. The government may consider using a cash payment policy and strengthening respite care programs. It is also worth noting that the quality of in-home care and community care might not be equal in different areas. Equipping caregivers with professional knowledge and ensuring the equality of services across regions are therefore critical in designing a successful service-delivery system. Finally, if the government plans to implement long-term care insurance in the future, then, in order to ensure its financial sustainability, a compulsory insurance scheme is needed to avoid adverse selection.