公義為綱、融資為目: 香港醫療制度改革的社會公義問題

Social Justice and Healthcare Reform in Hong Kong

Abstract

LANGUAGE NOTE | Document text in Chinese; abstract also in English.

本文討論香港醫療制度的融資安排與改革，並探討進行改革所帶來的社會公義問題。本文認為一個符合社會公義的公共醫療制度要保證市民得到一個得體而又最基本（decent minimum）的服務，這個服務水平要由一個公開和有廣泛公眾參加的醫療配給制度。本文建議香港確立一個這樣的配給制度監按公共醫療服務的增長，並且透過改革收費制度或輕微地增加稅收，便可以在符合社會公義的大前提下解決融資安排問題。本文反對採用強制性儲蓄計劃、保險計劃或保健組織（HMO） 制度對香港的醫療制度進行改革，因為這些供款計劃會帶來不少道德危險問題，有違社會公義。

This paper discusses the financial arrangement of the healthcare system and the issues of justice arising from healthcare reform in Hong Kong. The current Hong Kong public healthcare system is quite efficient. The population of Hong Kong has higher life expectancy and lower infant and maternity mortality rates than that of many developed countries, such as the United States. However, the public expenditure in healthcare in Hong Kong only amounts to 2.18% of GDP. This is much lower than most of the developed countries although the per capita income of Hong Kong has surpassed that many industrialized nations, including Canada and Australia. But more than 90% of the hospital services is provided by public hospitals. Moreover, the all-inclusive per diem hospital charge is HK$68 (roughly US$8.5), which only covers 2% of the average cost of a patient day, and so the system is almost universally accessible as well. In fact, since 1974, the government has adopted the policy that no one should be denied adequate medical treatment through lack of means.

However, the current system has been under stress mainly for three reasons: (1) aging population, (2) increasing medical expenditure arising from the advancement of medical technology, and (3) rising expectation from the community triggered by the rapid economic development over the past one to two decades. Various proposals have been put forward to reform the healthcare system in Hong Kong so as to make it more financially sustainable in the long term. These proposals include:
increase in personal and corporate income tax;
increase in the per diem charge of public health care services;
mandatory savings scheme;
coordinated voluntary or mandatory insurance scheme;
health maintenance organization scheme.

This paper concedes that healthcare reform is not only a technical issue in financial management, but will have long term impact on the distribution of healthcare benefits and burdens in Hong Kong society. So the problem of justice must be addressed before launching any healthcare reform plan.

This paper discusses the major approaches to the justice problem in healthcare financing. The libertarian approach is rejected because the free market mechanism advocated by the approach, such as voluntary insurance schemes, will put the worse off in a vulnerable position. The paper on the one hand agrees with the egalitarian approach that the claims of healthcare needs have their moral force, but on the other hand maintains that the egalitarian approach may overburden the public healthcare system. Based on the ideas of public choice theory and socialized care, it is argued that a just healthcare system needs only to guarantee a decent minimum level of healthcare services for all that is regarded as affordable by the general public.

The paper maintains that what constitutes such a level of services should be determined by a rationing system. Various utilitarian approaches to rationing are critically examined. It is found that although these approaches provide useful indices for decision-making in healthcare rationing, none of them could provide a mechanical procedure that could substitute for a fair deliberative process. The paper argues that the decent minimal level of healthcare services guaranteed for all should be determined by an open and a democratic process, and recommends that such a rationing system be set up in Hong Kong.

Since various performance indices have shown that the healthcare system in Hong Kong is quite efficient, the claim that the existing system is "on the verge of reaching a crisis situation" is likely to be an exaggeration. Those who uphold this claim tend to support the more radical proposal of introducing various contributory schemes, including proposals (3) - (5), to reform the financial arrangement of the existing healthcare system. The paper rejects this approach, because social justice could be undermined by the moral hazard problems created by these contributory schemes and the government would consequently not be able to uphold the policy already adopted in 1974, which guarantees that no one will be denied adequate medical treatment because of inability to pay.

It is believed that the stress of the public healthcare system in Hong Kong can be alleviated to a large extent by setting up an open and a democratic rationing system to monitor the increase of medical costs, a modest increase in service charges, a further improvement in the efficiency of the existing system, and perhaps a small increase in tax rates too. For the sake of justice, as the paper maintains, the government must be very cautious in adopting any more radical reform initiative.

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