Abstract
In the tradition of economic sociology, this study aims to investigate the paradox of national health insurance (NHI) in terms of both the de-commodification and re-commodification of national welfare policies. Our focus is on payment systems that facilitate the transactions among the state, medical institutions, and the insured with specific social missions. The state government provides medical services for people via mechanisms of payment systems under the scheme of NHI. On the one hand, these mechanisms de-commodify national welfare policies. On the other hand, the underlying economistic fallacy drives the recommodification of medical services, hence erodes doctor-patient trust relationships and caused severe financial crises of NHI system. Taiwan Capitation Pilot Study (TCPS) is an important step in reforming our national health policy. This innovative payment system was meant, in the spirit of “holistic health care” to achieve the ideal of “purchasing health for the people instead of purchasing medical services” through the integration of regional medical systems and the establishment of community-based health promotion programs. Our field study was predicated on experiences of experimental teams of TCPS, teams of ‘family physicians integrated delivery systems,’ and those of community medical workers. We find that TCPS failed to establish stable doctor-patient relationships, nor did it encourage family physicians to be fully embedded in community lives to create a mediating platform for personal health management and community health promotion. The community-based health policy points to the importance of grounding health care in communities, arousing inspirations for health, and generating the social space for collective action through innovative institutional design. In this sense, TCPS is important to Taiwan’s health policy precisely because it is a payment system reform predicated on community-based health promotion. Through operations of community health center, TCPS redefine a new health care eco-system to cope with future population structure of Taiwan. First of all, I review the implementation of main community policies, including medical services, social welfare and community building. The marginalization and fragmentation of community policies made it difficult for TCPS to implement community-based health policy. In the end, TCPS is hard to overcome the problem of the disembedded relationships between family physicians and community. Secondly, the ideology of fee-for-service payment distorted the policy orientation of TCPS, making, unfortunately, the cost-down of medical services and the budgetary control the ultimate goal of healthcare reform. In order to obtain reimbursement for case management, TCPS medical teams had to compromise with NHI by accepting its key performance indicators. This kind of benchmarking reduced the latitude of TCPS medical teams to develop community-specific kind of health promotion projects. Our fieldwork observations showed that under the monitoring by Departments of Social Welfare community development associations managed to sustain, facing the shortage of money and human resources. The main reason why community development associations were able to continue the operation of community care system is attributed to the inter-personal social trust of Taiwanese society. Interpersonal trust helped break the policy constraints and consolidate community to overcome financial challenges. Some community organizations tried to develop sharing economy and community enterprises to solve financial problems. They aspired to create a socially empowered, democratic and maximized community interests platform to solicit as much resource as possible. Unfortunately, it is hard for community organizations to acquire sustainable development ability due to the legal and institutional limitations. In conclusion, this study attempted to explore the possibility of integrating medicine, social welfare and culture from the vantage point of social economy, social trust and community-based health. In the spirit of real utopia, we proposed a solution dubbed ‘community health circuit’. ‘Community health circuit’ empowers communities and cultivates social, financial, environmental proficiency as well as the ability to build up a cross-disciplined cooperative platform, the ultimate goal of which is to fully ground TCPS in local communities to promote health for all the concerned citizens. Keywords: payment system、NHI、capitation、social trust、health promotion