臺灣全民健保簡介[中文+英文]

臺灣全民健保簡介

課程訓練部 醫學六 高瑞鴻 製作

中文簡介 :

(選輯自維基百科)

全民健康保險，一般簡稱為「全民健保」或「健保」，是中華民國依據《中華民國憲法增修條文》所實施的全民醫療保險制度。第二次世界大戰結束後的台灣，原本只有勞工保險（勞保）、農民保險（農保）、公務人員保險（公保）等醫療保險，無法照顧到全體國民。為增進全體國民健康，台灣於1995年3月開始實施全民健康保險，以提供醫療保健服務，主要法律依據為《全民健康保險法》。

        全民健康保險唯一辦理及管理機構，是行政院衛生署下轄的中央健康保險局（簡稱中央健保局），為一官方機構。此種「公營單一社會保險制」的醫療照顧體系（health care system），則類似加拿大的制度。

台灣實施全民健保時，為了將公保、勞保、農保、軍保的舊有保險體系整合納入全民健保中，故而採取依身份別強制納保的制度。不同身份的加保人不因健康病史問題而有不同保費，而是根據行業身份而有不同納保費率。民眾加保後，以健保卡到醫療院所就醫時即僅須負擔掛號費以及部份負擔費用。而醫療院所則是以量計酬，根據病患病歷就診紀錄向健保局請領醫療給付。

但由於1995年實施全民健保後，醫療開支大幅增加，遠超過原核定保費所能支應。故而健保局引入健保總額支付制度來控制財務風險。亦即健保局不再全額給付醫療院所的醫療支出費用，而是在事前劃定一個醫療支出費用的總額，由醫療院所各自申請後，若申請總額低於原訂總額則全額給付，若申請總額高於原訂總額，則按比例打折給付。

直接優點：

若國民若身患重病，可以大幅減少家庭及個人財務負擔，尤其是在病患一旦罹患重症(例如癌症)，除了少部份自費負擔外大多數醫療費用都有高額的補助。而健保平時也能補貼一般疾病的開支，減輕民眾醫療的負擔。也因此全民健保的滿意度一直是居高不下。

健保提供福利：

健保局公告癌症，先天性疾病...等等疾病為「重大傷病」，合乎規定的被保險人至健保合約醫療院所就醫時，得免繳交部分負擔。

健保附有免費健康檢查福利，唯宣傳較少不為一般大眾所知，在2400家參與免費健康檢查服務的診所或醫院，40歲以上每3年一次65歲以上每年一次可以要求免費健康檢查。檢查內容為身體檢查、健康諮詢、血液檢查、尿液檢查四項。

財務優點：

總額給付制把保險不給付的風險轉嫁給醫院，全民健保與商業保險一樣會找理由不給付，但是商業保險是由病患個人承擔保險公司不給付的風險，而全民健保則是由醫院先行承擔，政府不負擔此一風險，而病患則是在醫院無法吸收虧損後才承擔風險。

全民健保降低商業保險的需求，而許多商業保險公司會把保費拿來投資土地，造成都會區高地價高房價，形同國民付錢給保險公司炒地皮。全民健保可能可以減輕這樣的狀況。

從經濟學的觀點來看，民眾因為負擔減輕而有誘因增加醫療需求，醫院因為以量計酬而有誘因增加醫療開支，所以這個保險本身就有傾向過度成長的誘因。而由於保費的調漲又受到非經濟的政治力左右，使得保費的調漲困難，不能迅速反應醫療開支的增長。這兩個結構性的因素致使全民健保的財務問題始終在難以永續執行的破產邊緣徘徊。

醫療開支過度成長

針對醫療開支過度成長的問題，健保局引入健保總額支付制度來控制財務風險。亦即健保局不再全額給付醫療院所的醫療支出費用，而是在事前劃定一個醫療支出費用的總額，由醫療院所各自申請後，若申請總額低於原訂總額則全額給付，若申請總額高於原訂總額，則按比例打折給付。這個措施延緩了全民健保的破產危機，然而非經濟因素造成的財務問題卻還是無解。

保費結構不良

另外以身份別、納保薪資為基礎的保費結構延續了早年政府照顧勞工、農民、軍公教人員的政策，會產生保費偏低的問題，而已納保薪資為基礎的保費結構，使得以資本利得為主要收入的富人並未負擔較高的保險費用，形成由受薪階級負擔全民健康的不公平現象。為此健保局也規劃了一點五代健保及二代健保，期望能解決財務及公平問題。一點五代健保是延續身份別納保，但是增加以資本利得為基礎的補充健保費，將本來以薪資收入為保費基礎擴大為以個人收入為保費基礎。二代健保則是停止身份別納保的制度，改以家戶收入為保費基礎。這兩種改革方式都是以擴大保費基礎來增加保費收入。

但全民健保保費徵收方案無論是單純修訂費率調漲或是結構性改善的調整方案都難以被國會以及民眾接受。衛生署提出調漲健保費的建議或是健保改革草案，也不容易得到支持。例如前衛生署長李明亮調漲保費費率後辭職，前衛生署長楊志良也在通過二代健保草案後辭職。由此即可看出要推動調漲保費與改善財務結構的困難性。

ENGLISH INTRODUCTION

Taiwan’s national health insurance (NHI) is administrated by the government. NHI is a compulsory for all citizens from birth, and its coverage is now more than 99%. Mutual assitance is the central concept of NHI. Once people pay the relatively low premium on time, they can choose to visit any hospital and doctor if they need medical care. And they can have treatment with very low copayment. Therefore, Taiwanese people have a very good accessibility to the healthcare system. The patients don’t have to worry about going bankrupt due to medical bills.

For example, the patient only has to pay 350NTD for a hernia repair surgery. Very inexpensive!! Another example is that in the era before NHI, once the patient was diagnosed with ESRD, he may need to sell his house to collect the money for chronic hemodialysis treatment. But this is not the case now in Taiwan. This is the bright side of Taiwan’s NHI.

Although there are a lot of good things from NHI, there are also many problems in Taiwan’s healthcare environment.

Because of the low copayment, “doctor shopping” is commonly seen in Taiwan. Also, because of the great number of patients, it is often for a doctor to see more than 50 patients in one morning, sometimes even more than 100! The patient may has to wait for a long time and only has a few minutes to see the doctor.

NHI uses many methods to control the expense, such as global budget and peer scrutinizing to limit the growth of medical expenses. For medical staff, the workload is heavy but the salary is relatively low. In some specific medical specialties like internal medicine, surgery, OBGYN, and pediactrics, these core departments of medicine are not the first choice of young doctors anymore. In addition, lack of nurses is also a problem in many hospitals because of the disproportionate workload and pay.

Generally speaking, NHI has been very good for patients, but it also makes the healthcare environment more and more unfriendly for doctors and nurses and cause many other problems.

INTRODUCTION ADAPTED FROM WIKIPEDIA

The current health care system in Taiwan, known as National Health Insurance (NHI), was instituted in 1995. NHI is a single-payer compulsory social insurance plan which centralizes the disbursement of health-care funds. The system promises equal access to health care for all citizens, and the population coverage had reached 99% by the end of 2004.[4] NHI is mainly financed through premiums, which are based on the payroll tax, and is supplemented with out-of-pocket payments and direct government funding. In the initial stage, fee-for-service predominated for both public and private providers. Most health providers operate in the private sector and form a competitive market on the health delivery side. However, many health care providers took advantage of the system by offering unnecessary services to a larger number of patients and then billing the government. In the face of increasing loss and the need for cost containment, NHI changed the payment system from fee-for-service to a global budget, a kind of prospective payment system, in 2002.

Even with all their success in their health care system, Taiwan has suffered some misfortunes. The government is not taking in enough money to cover the services it provides, so it is borrowing money from banks.[15] The revenue base is capped so it does not keep pace with the increase in national income. Premiums are regulated by politicians[16] and they are afraid to raise premiums because of voters. The country is slow at adopting technology except for drugs. There is a low doctor-to-population ratio resulting in too many patients depending on too few doctors. Patients visit the doctor more frequently causing doctors to keep visits short to about 2 to 5 minutes per patient.[17] There is no system to regulate systematic reporting of clinical performance, patient outcomes and adverse events.