| Abstract: | 德國法定健康保險制度建立於1883年，其制度特徵包括以受薪階級而非體國民為強制投保對象、多元複數健保保險人、具有公法上社團法人性質之社會自治、集體協商公法性質之醫事服務提供契約、保險支出由勞資雙方負擔國家未給予一般性補助。近年來因經濟及人口結構等因素變遷，影響其運作效能與財務健全度。 2007年基於兩大政黨的政策共識大幅修正德國社會法典第五編法定健康保險法之規定，其重要措施包括：以法定健康保險與商業健康保險雙軌併進實施全民強制投保，政府統一訂定保費費率，以保費收入及政府補助設立健保基金由政府集中管理，再依年齡、性別、疾病等風險群組將保費收入分配給各健保保險人，各健保保險人在分配預算下得向個別健保醫師購買服務，收支不平衡時並得向其被保險人加收附加保費，被保險人則享有轉換保險人之權利。經此改革，德國健康保險制度之內涵與組織方式與以往相較，社會互助與風險分攤機制由分散化轉為集中化，保險營運強調競爭與效能，國家則扮演積極政策調控角色。 德國法定健康保險與我國全民健保制度不盡相同，但德國健保財務運作基本原則、多元複數健保組織與社會自治、集體協商機制與法律關係之定性等一直是國內文獻檢討我國健保問題、提出革新方案的重要學術論據，並為大法官解釋所採納。本研究將以大法官釋字第609號解釋所揭示的強制投保、社會互助與風險分攤原則作為切入點，說明德國2007年健康保險制度改革之重要內容、組織體制及其引發之法律爭議，並與我國二代健保及2011年修法相關議題進行分析比較。
The German social health insurance systems funded in 1883 were characterized by the fallowing elements such as the compulsory insurance mainly for employees but not for whole citizens, plural health insurance agencies, social self-governance with a legal form of public corporation, collective negotiation regulated and defined by the public law, all expenditure financed by payroll tax and shared by the employees and employers without fixed governmental subsidies. In recent years the efficiencies of the public health care systems and their financial balance are continuingly challenged by the disadvantageous development of economic and demographical factors. In order to maintain the stability of contributions rate, in 2007 the Social Health Insurance Act in the 5. Volume of Social Law Code has been fundamentally amended based on the reform consensus between the two mainly political parties. According to the new Act, all citizens are compulsorily involved in the health care system, while private health insurers have to offer a “basic care package” which mimics the condition of social health insurance. Furthermore, the income-related premiums rate of social health insurances shall be determined uniformly by the government; the government collects contributions and federal subsidies to establish a central health fund for social health insurance, then distributes money among health insurance agencies adjusted by the risks structure of sex, aging and morbidity; within the annual revenue the agencies can directly negotiate with medical care providers, in financial difficulty they must request supplemental flat-rated payments directly from insureds, on the other hands the insureds in turn are free to switch to other agencies. Comparative to the former systems, the legislators reorganize the fragmental mechanism of solidarity and risks sharing to create a centralized institute, impose pressure of competition among the health insurance agencies, while the government plays a more active role as policies maker. The Bismarck-model of social insurance system is influential in the reform discussions of National Health Insurance (NHI) in Taiwan irrespective of several differences between the two institutions; the financial operation system, the plural agencies, the social self-government, the collective negotiation and the legal relationship among insureds, insurers and medical care providers of German health insurance systems were often considered in the 2nd generation NHI, and some legal points have been also adopted by the Grand Justices in the Constitutional Interpretations. According to the above, this research is conducted to analyze the legal issues and organizational institution relating to compulsory insurance, solidarity and risks sharing declared by the Constitutional Interpretation No. 609 with comparative perspectives of the NHI reform 2011 in Taiwan and the health care reform 2007 in Germany. |
