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系統識別號 U0002-0909200916381900
中文論文名稱 柯林頓政府醫療改革推行之研究
英文論文名稱 The Analysis of U.S. Clinton Administration’s Health Care Reform
校院名稱 淡江大學
系所名稱(中) 美國研究所碩士班
系所名稱(英) Graduate Institute of American Studies
學年度 97
學期 2
出版年 98
研究生中文姓名 林郁芬
研究生英文姓名 Yu-Fen Lin
學號 692220022
學位類別 碩士
語文別 中文
口試日期 2009-07-27
論文頁數 68頁
口試委員 指導教授-李本京
委員-黃介正
委員-劉興漢
中文關鍵字 柯林頓  希拉蕊  健保  社會福利  管理式競爭  健康維護組織 
英文關鍵字 Clinton  Hillary  health care  social welfare  managed competition  Health Maintenance Organization 
學科別分類 學科別社會科學區域研究
中文摘要 本論文之研究主旨在探討美國柯林頓政府任內改革健保制度並試圖推行全民健保所作探討的策略。一九九○年代初,健保費用高漲及保險給付降低,造成失去保險的人數不斷增加,健保成本攀升造成政府赤字不斷膨脹,在此背景之下,逐漸演變成為要求健保改革之運
動。柯林頓甫上任便兌現其競選承諾,指派希拉蕊主導健保改革之策劃,目標在於使全民皆享有健康保險及減輕政府財政之負擔。在當時民主黨掌握白宮及國會雙重優勢情況下,本有機會通過其所支持之法案,然於推行過程中,未能多方徵詢各方意見,加上反對聲浪頗大,因而此立意良善之計劃,最後仍功虧一簣,未能成為法律。而健保計劃推行的失敗,亦間接造成民主黨一九九四年國會期中選舉的挫敗,讓出了參眾兩院多數黨的位置。
經分析其提案內容及推行過程,可看出:其一,未能與反對黨針對健保計劃進行有效之協商,同黨議員亦缺乏共識;其二,多數利益團體被排除參與計畫工作小組 (task force),深怕既有利益被剝奪,反而形成一股強大的反對力量;其三,柯林頓高估了其政治實力
,並且未趁勝選掌握提案最佳時機,經濟復甦更降低民眾健保改革之需求:其四,計畫內容缺乏簡單易懂之目標,並且未經多方辯論,難以說服美國人接受這一套計劃;其五,政府過度干預健保市場,容易被批評成大政府 (big government),並且與美國人崇尚個人主義
及自由放任思想有所牴觸。種種情勢之誤判,交互影響造成此一提案之挫敗。
因此本論文內容,於第一章說明研究動機、目的、限制與範圍;第二章則簡述美國至九○年代止社會福利發展之沿革,並敘述各總統任內有哪些主要健保措施;第三章則針對柯林頓政府當時提案之背景、健保計劃之內容及施行策略、以及提案之後所引發的反對聲
浪及期中選舉失敗陳述;第四章則主要分析健保改革計劃挫敗之因素,及所面臨的困境為何。第五章為結論,歸納前述章節所述,敘述後代有意改革美國健保制度者可從中獲得何種教訓,避免重蹈覆轍。
英文摘要 The purpose of this thesis is to analyze the U.S. Clinton administration’s health care reform and the attempt to have the universal coverage of health insurance in the U.S. In 1990s, the escalating health care costs and declining coverage was mainly the outcome of an increasing number of uninsured Americans. The rising health care cost had helped a prolonged swell of the deficit. These problems led to a powerful movement requesting health care reform. Clinton, when took office, fulfilled his campaign promise by appointing the First Lady Hillary Clinton to chair the task force on national health care reform with the aim of having universal coverage of health insurance and reducing the heavy financial burden on government. Being a Democratic President having a Democratic majority in the Congress, Clinton could have stood on a vantage point to pass the Health Security Act he advocated. Nevertheless, the proposal fell short of success due to a combination of factors (e.g. failing to include varied opinion, the rising objection and doubtfulness to the proposal itself), which further frustrated the Democrats in 1994 congressional election and the Republican Party regained a majority of seats in the House and Senate since 1954.
By investigating the proposal and process of approval, it is clear that the following factors should share the responsibility for the failure of Health Security Act. First of all, Clinton failed to negotiate with the opposition party in terms of the content and even Democrats lacked for consensus in Capitol. Secondly, lots of interest groups were not taken into account in the task force and instead started to advocate against the proposal and to criticize it with the fear of losing the vested interests. Third, Clinton misjudged his political strength and failed to recognize the limit of his authority and missed the best time to propose the Health Security Act. Economic improvement also slowed the momentum for health care reform. Fourth, it may not be easy for Americans to take a plan without core principles and had not been debated in public. What’s more, the proposal was criticized about its interference in the health insurance market to an extent of big government, which contradicted the thinking of individualism and laissez-faire in the U.S. These factors led to the defeat of the proposal in 1994.
In this thesis, chapter one is the introduction including the motivation, purpose and framework of this study. Chapter two discusses the brief history of social welfare system in the U.S. and previous policies on health care. Chapter three analyzes the background, target, content of Clinton’s proposal and the reaction after it was proposed. Chapter four mainly focuses on the reasons that cause the defeat of Clinton’s health care reform. Chapter five is the conclusion.
論文目次 章節目錄

第一章 緒論……………………………………………………………………1
第一節 研究動機與目的………………………………………………………1
第二節 研究方法、章節安排、研究限制及文獻回顧………………………5
第二章 美國社會福利發展之回顧……………………………………………9
第一節 美國早期社會福利概況 ……………………………………………9
第二節 美國社會福利發展之沿革 …………………………………………12
第三章 柯林頓政府健康保險改革政策之概況 ……………………………17
第一節 柯林頓政府健康保險政策之制訂背景 ……………………………17
第二節 國會健康保險制度的主要改革方式提案 …………………………21
第三節 方案制定的內容分析 ………………………………………………26
第四節 改革提案之後續發展 ………………………………………………35
第四章 各界對於柯林頓健保改革方案的看法 ……………………………42
第一節 反對改革方案的論述 ………………………………………………42
第二節 柯林頓方案失敗原因之探討 ………………………………………47
第五章 結論 …………………………………………………………………57
參考書目……………………………………………………………………………..62

表目次

表3-1 一九五○至一九九○年代醫療費用增長的情形…………………………19
表3-2 柯林頓健康保險改革之明確目標及施行策略……………………………29
表3-3 改革方案主要項目及內容…………………………………………………30
表3-4 一九九四年美國期中選舉(眾議員)各政黨席次消長表………………….40
表3-5 一九九四年美國期中選舉(參議員)選舉前後席次變化………………….41

參考文獻 參考書目
中文部分
一、專書:
李中興著,柯林頓經濟學:振興美國經濟的新策略,台北:卡來,民國八十六年。
林萬億,台灣的社會福利:歷史經驗與制度分析,台北:五南,民國九十五年。
林立樹著。美國通史,台北:立緒,民國八十四年。
司徒佩琪著。希拉里畫傳,北京:東方,民國九十四年。
美國心理協會原著,陳玉玲、王明傑編譯。美國心理協會出版手冊 (五版):論
文寫作格式,台北:雙葉,民國九十四年。
查爾斯‧蔡斯卓著,張英陣 等譯。社會福利與社會工作,台北:洪葉文化,民
國八十八年。
馬克思‧韋伯著,于小 等譯。新教倫理與資本主義精神,台北:左岸文化,民
國九十年。
彭滂沱著。打造美國總統:從羅斯福到柯林頓的決策領導,台北;時報,民國
十六年。
張家洋著。美國羅斯福總統新政時期社會安全制度的發展,台北:臺灣商務,民
國六十二年。



二、學術論文:
魯銘鍾著。柯林頓總統執政時期平衡美國預算赤字之研究,台中:東海大學政治研究所碩士論文,民國九十二年。

三、中文期刊:
袁征。總統遊說與國會決策,美國研究 (中國社會科學院美國研究所、中華美國
學會主辦),第三期,民國九十年。
秦斌翔。克林頓的醫療改革,美國研究 (中國社會科學院美國研究所、中華美國
學會主辦),第四期,民國八十三年。
張奇林,美國醫療保障制度評估,美國研究 (中國社會科學院美國研究所、中華
美國學會主辦),第一期,民國九十四年

英文部分
1. Books
Aaron Henry J., eds. The Problem That Won’t Go Away: Reforming U.S. Health
Care Financing, Washington D.C.: The Brookings Institution, 1999.
Bilheimer, Linda, and Robert Reischauer, “Estimating the Effects of
Reform”, The Problem That Won’t Go Away: Reforming U.S. Health Care
Financing, ed. Ed. Henry J. Aaron, Washington, D.C.: The Brookings
Institution, 1996.
Clinton , Hillary Rodham, Living History, New York: Scribner, 2003.
Denton, Robert E. Jr., and Rachel L. Holloway, The Clinton Presidency: Images,
Issues, and Communication Strategies, Westport, CT: Praeger Publishers,
1996.
Ferrara Peter J. and Michael Tanner. A New Deal For Social Security,
Washington D.C.: CATO Institute, 1998.
Gergen, David, Eyewitness to Power, New York: Simon & Schuster, 2000.
Heclo, Hugo, “Clinton’s Health Reform in Historical Persective”, The Problem
That Won’t Go Away: Reforming U.S. Health Care Financing, Ed. Henry J.
Aaron, Washington, D.C.: The Brookings Institution1996.

Heirich Max. Rethinking Health Care: Innovation and Change in America,
Boulder, Colorado: WestviewPress, 1999.
Johnson Haynes and David S. Broder, The System: The American Way of
Politics at the Breaking Point, Boston: Little, Brown and Company, 1996.
Karger Howard Jacob and David Stoesz. American Social Welfare Policy: A
Pluralist Approach, New York: Longman, 1994.
Kotlikoff Laurence J., and Scott Burns, The coming Generational Storm: What
You Need to Know about America’s Economic Future, (Cambridge,
Massachusetts: The MIT Press, 2005.
Krugman, Paul, The Conscience of a Liberal, New York: Norton, 2007
Laham, Nicholas, A Lost Cause: Bill Clinton’s Campaign for National Health
Insurance, Westport, CT: Praeger Publishers, 1996.
Lundberg, George D. Severed Trust: Why American Medicine Hasn’t Been
Fixed, New York:Basic Books, 2001.
Miringoff, Marc L. and Sandra Opdycke. American Social Welfare Policy:
Reassessment and Reform, Eaglewood Cliffs, New Jersey: Prentice Hill, 1986.
Mueller, Keith J., Health Care Policy in the United States, Lincoln, NE:
University of Nebraska Press, 1993.
Patel, Kant, and Mark E. Rushefsky, Health Care Politics and Policy in
America, New York: M. E. Sharpe, 1995.
___Politics, Power & Policy Making: The Case of Health Care Reform in the
1990s, New York: M. E. Sharpe, 1998.
Peterson Wallace C., The Socil Security Primer, New York: M.E. Sharpe, 1999.
Quadagno, Jill, One Nation, Uninsured, New York: Oxford University Press,
2005.
Reichard , Gary W., and Harlan Davidson, Politics As Usual: The Age of Truman
and Eisenhower, Wheeling, Illinois: Harlan Davison, 2004.
Watson, Robert P., The Presidents' Wives: Reassessing the Office of First
Lady, Boulder, Colorado: Lynne Rienner, 2000.
Zelman, A. Walter. The Changing Health Care Marketplace: Private Ventures,
Public Interests. San Francisco: Jossey-Bass Publishers, 1996.

2. Journals
Braithwaite, Jeffrey, “Health-Care Reform Under President Clinton: Issues, Ideas
and Implications,” Australian Journal of Public Administration, Vol. 54
Issue 1, 1995.
Gorin, S, “Universal Health Care Coverage in the United States: Barriers, Prospects, and Implications,” Health and Social Work, Vol.22, 1997.
Grumbach, Jake, “Single-Payer Healthcare”, Policy Studies Journal, Volume: 35. Issue: 3, 2007, p.532
Jesilow, P., Geis, G., & Harris, J. C, “Doomed to Repeat Our Errors: Fraud in Emerging Health-Care Systems,” Social Justice, Vol.22, 1995.
Matthews Merrill Jr., and Molly Hering, “The Clinton Plan”, National Review, Vol. 45 Issue 24, December 13, 1993, p8-9.
Miller, M. L., Tinsley, R., Easley, W. F., & Serotta, A, “How Will President Clinton's Health Care Reform Plan Affect Employers and CPA Firms?” Journal of Accountancy, Vol.177, 1994.
Patel, Kant, “Presidential Rhetoric and the Strategy of Going Public: President Clinton and the Health Care Reform,” Journal of Health & Social Policy; Vol. 18 Issue 2003.
Thorpe, Kenneth E, “Protecting the Uninsured,” New England Journal of Medicine, Vol. 351 Issue 15, 2004.

3. Newspaper
Eckholm, Erik, “Clinton’s Health Plan: The Consumers; A Benefit for Some
Patients, Difficult Choices for Others ,”New York Times, September 11,
1993
Pear, Robert, "Health-Care Costs Up Sharply Again, Posing New Threat," The
New York Times, January 5, 1993,

4. Websites
Address on Health Care Reform by Bill Clinton, (September 22, 1993),
published on the website
Clinton, Bill. Health Security Act and related files, published on the website of
Congressional Printing Office.

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