到國家主義之路：路徑依賴與全民健保組織體制的形成

Path Dependence and the Institutional Formation of Taiwan's National Health Insurance Plan

本文使用路徑依賴的概念來解釋為何台灣的全民健保會建立「政府經營的單一體系」這種國際上罕見的「國家主義」組織體制。本文的分析有兩條主軸。在第一條軸線上，我分析制度起源時期所建立的「國家經營、體系分立、事權分散」的組織體制，如何限制擴大保險對象的行動選擇，而非意圖地使勞工保險建構了跨階級的連帶，另一方面卻又造成社會保險體系極端的結構分歧。在第二條軸線上，我分析執政菁英一貫採取的低保費政策，其自我增強的過程，如何使結構分歧的保險體系在1980 年代末期陷於嚴重的財務危機。在危機中，既存組織體制存續的合理性遭致質疑，而國家主義方案，因為其被賦予的效率功能，以及風險分攤效果有助於政府從財務危機中脫困，而成為執政菁英解決危機的行動選擇。國家主義方案雖在決策過程中遇到部分國家機關和朝野立委的抗拒阻力，不過，由於勞保體系業已形成跨階級的連帶，單一體系整合並未引發社會階級／群體的衝突，因而弱化了反對的力量，另一方面，國家控制保險組織的長期歷史，也使民間經營的替代方案缺乏可信度和可行性。長期的歷史過程，創造了有利國家主義方案的行動條件。

The concept of path dependence is used to explain the statist character of Taiwan's national health insurance program-that is, why the state decided to adopt a single plan under its centralized control that covers the entire population. At the first level, I look at the reasons why social insurance programs created in the 1950s by the authoritarian state placed constraints on the classification of occupational groups that were covered. A series of decisions in this area unexpectedly expanded the social bases of the labor insurance program and fragmented individual social insurance regimes. At the second level, I show how the self-reinforcing low premium-rate policy led to a fiscal crisis in social insurance programs in the late 1980s-the same time that a national heath insurance plan was being constructed. During the crisis, existing structures within the fragmented and administratively decentralized social insurance program were discredited and reorganized into a single state-managed plan. Claiming that there were advantages in terms of efficiency and cross-subsidization, this structure was promoted by the state elite as a means of ending the crisis. Since the previous labor insurance program had paved social bases broadly, a statist project integrating labor insurance and other occupational programs into a single health insurance plan was accepted with little conflict among social groups that could have mobilized large-scale resistance. Since Taiwan's social insurance systems had long been controlled and managed by the state, a society-managed system was not considered feasible as an alternative. Thus, historical processes created favorable conditions for the establishment of the statist plan.