事在人為：健保局初期治理的行動分析

The Human Dimension: An “Action Analysis” of the Nascent Stage of the National Health Insurance

我國的全民健康保險在開辦之初，多半意見均不看好。這些「不看好」是根據「合理」、「一般情況正確」的理論為基礎，例如以「自由競爭」為圭臬，質疑健保「公辦公營」的單一體制必然會產生無效率的「腐化」結果，有部分人士甚至預言健保在短期間內將垮。然而，健保實施的結果，雖然有許多問題，但享有民眾高度的肯定，且若干指標亦顯示健保並未如當初一般人認定即將垮的立即危險，甚至從某些角度來看，有逐步趨穩的態勢。本文的起點即由健保實施的經驗質疑「一般正確」的理論何以無法預測健保的活存力，因而，捨棄一般正確的理論，一空依傍，採用「植根理論方法」，從健保組織的實地訪談中，重新建構可以詮釋健保「成就」的理論基礎。本文發現，健保開辦之初，制度面屢受批判不說，內外情況也均極困難：沒有前例可循，任何狀況都要靠創意來面對；民眾預期很高，應付需求疲於奔命；政治干預無所不在，凡事動輒得咎；社會不同群體之利害關係糾結，經常順了姑意就逆了嫂意。在這樣的情境下，健保基本上基於「人」的因素，乃能度過初步的考驗而站穩腳跟；隨後健保局同仁慢慢體會工作受到社會大眾的肯定、在制度草創下，反有自由揮灑的空間；且福利較一般公務機關優厚，也形成積極進取的動機。部分從原有社會保險體系中轉任的同仁，更體會「退此一步、即無死所」的情境，因此樂得在長官所刻意創造出來的不確定情況下「拼起來」。因此，健保乃能從篳路藍縷走向小康。然而，由於若干結構性不確定性因素始終不能消除（如改為民營），社會多元需求有增無減，健保財務日益困難，健保同仁需要新的知識、新的願景、新的理念的加持，健保的活力才能日新又新。

The National Health Insurance (NHI) Program of Taiwan was not, so to speak, born with a silver spoon in the mouth. Instead, many people wouldn’t bet a dime on its survival ability. The pessimistic comments on NHI were actually well-grounded. For instance, the monopolistic, public-run Bureau of NHI drew heavy fires from the economists who subscribed to the paradigm of neoclassical economics right along, and predicted that the NHI will fail in a matter of a few years for inefficiency and corruption. Yet, despite a myriad of problems just like every program like this around the world, NHI is alive and kicking and enjoying high approval rate and popularity among the people. At least NHI has not failed as predicted by some. This study begins by calling into question the validity of those “generally correct theories”, and, with a research method calling for on-the-site interviews, makes efforts to cast new paradigm for the NHI. The “grounded theory” method was chosen to draw the new explanation for the survival of the NHI program. We found that, at the nascent stage of the NHI, in addition to battered institutional arrangements, the situation was less than friendly to the NHI staff. As a newly established program, there were no routines to follow; easily to draw fires under tense conflict between various interest groups; elevated expectation on the part of the public was hard to meet; political interference was everywhere…It was the “human action” that hold the line and let the NHI take hold in the first place. The NHI staff gradually found the mission challenging and it was fulfilling to carry out this unprecedented job. And NHI was able to pull off from a myriad of crises. Yet, the NHI staff would need new visions, new knowledge, and new paradigm if the NHI program is to sail into the next decade in an even tougher environment of enduring uncertainty, increasing expectation, and worsening financial situation.