發文單位：司法院
解釋字號：釋字第550號
解釋日期：民國91年10月4日
解釋爭點：健保法責地方政府補助保費之規定違憲？
資料來源：司法院公報 第 44 卷 11 期 12-42 頁
                    司法周刊 第 1103 期 1 版
                    司法院大法官解釋（十五）（99年5月版）第 247-293 頁
                    總統府公報 第 6489 號 8-48 頁
                    法務部公報 第 292 期 50-83 頁
                    法令月刊 第 53 卷 10 期 78-79 頁
                    守護憲法 60 年 第 250-252 頁

相關法條：中華民國憲法 第 107、108、109、110、155、157 條 ( 36.01.01 )
                    中華民國憲法增修條文 第 10 條 ( 89.04.25 )
                    地方制度法 第 18、19 條 ( 88.01.25 )
                    社會救助法 第 19 條 ( 89.06.14 )
                    財政收支劃分法 第 37、38-1、4 條 ( 88.01.25 )
                    全民健康保險法 第 14、27、68 條 ( 91.07.17 )

解釋文：
國家為謀社會福利，應實施社會保險制度；國家為增進民族健康，應普遍推行衛生保健事業及公醫制度，憲法第一百五十五條、第一百五十七條分別定有明文。國家應推行全民健康保險，重視社會救助、福利服務、社會保險及醫療保健等社會福利工作，復為憲法增修條文第十條第五項、第八項所明定。國家推行全民健康保險之義務，係兼指中央與地方而言。又依憲法規定各地方自治團體有辦理衛生、慈善公益事項等照顧其行政區域內居民生活之義務，亦得經由全民健康保險之實施，而獲得部分實現。中華民國八十三年八月九日公布、八十四年三月一日施行之全民健康保險法，係中央立法並執行之事項。有關執行全民健康保險制度之行政經費，固應由中央負擔，本案爭執之同法第二十七條責由地方自治團體補助之保險費，非指實施全民健康保險法之執行費用，而係指保險對象獲取保障之對價，除由雇主負擔及中央補助部分保險費外，地方政府予以補助，符合憲法首開規定意旨。
地方自治團體受憲法制度保障，其施政所需之經費負擔乃涉及財政自主權之事項，固有法律保留原則之適用，但於不侵害其自主權核心領域之限度內，基於國家整體施政之需要，對地方負有協力義務之全民健康保險事項，中央依據法律使地方分擔保險費之補助，尚非憲法所不許。關於中央與地方辦理事項之財政責任分配，憲法並無明文。財政收支劃分法第三十七條第一項第一款雖規定，各級政府支出之劃分，由中央立法並執行者，歸中央負擔，固非專指執行事項之行政經費而言，惟法律於符合上開條件下，尚非不得為特別之規定，就此而言，全民健康保險法第二十七條即屬此種特別規定。至全民健康保險法該條所定之補助各類被保險人保險費之比例 屬於立法裁量事項，除顯有不當者外，不生牴觸憲法之問題。
法律之實施須由地方負擔經費者，如本案所涉全民健康保險法第二十七條第一款第一、二目及第二、三、五款關於保險費補助比例之規定，於制定過程中應予地方政府充分之參與。行政主管機關草擬此類法律，應與地方政府協商，以避免有片面決策可能造成之不合理情形，並就法案實施所需財源事前妥為規劃；立法機關於修訂 相關法律時，應予地方政府人員列席此類立法程序表示意見之機會。

理由書：
國家為謀社會福利，應實施社會保險制度；國家為增進民族健康，應普遍推行衛生保健事業及公醫制度；國家應推行全民健康保險及國家應重視社會救助、福利服務、 國民就業、社會保險及醫療保健等社會福利工作，對於社會救助和國民就業等救濟性支出應優先編列，乃憲法第一百五十五條、第一百五十七條暨憲法增修條文第十 條第五項、第八項所明定之基本國策。憲法條文中使用國家一語者，在所多有，其涵義究專指中央抑兼指地方在內，應視條文規律事項性質而定，非可一概而論。憲 法基本國策條款乃指導國家政策及整體國家發展之方針，不以中央應受其規範為限，憲法第一百五十五條所稱國家為謀社會福利，應實施社會保險制度，係以實施社 會保險制度作為謀社會福利之主要手段。而社會福利之事項，乃國家實現人民享有人性尊嚴之生活所應盡之照顧義務，除中央外，與居民生活關係更為密切之地方自 治團體自亦應共同負擔（參照地方制度法第十八條第三款第一目之規定），難謂地方自治團體對社會安全之基本國策實現無協力義務，因之國家推行全民健康保險之義務，係兼指中央與地方而言。八十三年八月九日公布、八十四年三月一日施行之全民健康保險法，係中央立法並執行之事項。有關執行全民健康保險制度之行政經費，依同法第六十八條全民健康保險所需之設備費用及週轉金（並人事、行政管理經費），固應由中央撥付，依憲法第一百零九條第一項第一款、第十一款暨第一百 十條第一項第一款、第十款，各地方自治團體尚有辦理衛生、慈善公益事項等照顧其行政區域內居民生活之責任，此等義務雖不因全民健康保險之實施而免除，但其中部分亦得經由全民健康保險獲得實現。本案爭執之全民健康保險法第二十七條責由地方自治團體按一定比例計算，補助各該類被保險人負擔之保險費，非屬實施全 民健康保險法之執行費用，乃指保險對象獲取保障之對價，而成為提供保險給付之財源。此項保險費除由雇主負擔及中央補助部分外，地方政府予以補助，合於憲法 要求由中央與地方共同建立社會安全制度之意旨，與首揭憲法條文尚無牴觸。本院釋字第二七九號解釋亦本此意旨，認省（市）政府負擔勞工保險補助費乃其在勞工 福利上應負之義務而釋示在案。
        地方自治團體受憲法制度保障，其施政所需之經費負擔乃涉及財政自主權之事項，固有法律保留原則之適用，於不侵害其自主權核心領域之限度內，基於國家整體施政需要，中央依據法律使地方分擔保險費之補助，尚非憲法所不許。前述所謂核心領域之侵害，指不得侵害地方自治團體自主權之本質內容，致地方自治團體之制度保障虛有化，諸如中央代替地方編製預算或將與地方政府職掌全然無關之外交、國防等事務之經費支出，規定由地方負擔等情形而言。至於在權限劃分上依法互有協力義務，或由地方自治團體分擔經費符合事物之本質者，尚不能指為侵害財政自主權之核心領域。關於中央與地方辦理事項之財政責任分配，憲法並無明文。財政收支劃分法第三十七條第一項就各級政府支出之劃分，於第一款雖規定「由中央立法並執行者，歸中央」，固非專指執行事項之行政經費而言，然法律於符合首開條件時，尚得就此事項之財政責任分配為特別規定，矧該法第四條附表二、丙、直轄市支出項目，第十目明定社會福利支出，包括「辦理社會保險、社會救助、福利服務、國民就業、醫療保健等事業及補助之支出均屬之」。本案爭執之全民健康保險法第二十七條即屬此種特別規定，其支出之項目與上開財政收支劃分法附表之內容，亦相符合。至該條各款所定補助各類被保險人保險費之比例屬立法裁量事項，除顯有不當者外，尚不生牴觸憲法問題。
法律之實施須由地方負擔經費者，即如本案所涉全民健康保險法第二十七條第一款第一、二目及第二、三、五款關於保險費補助比例之規定，於制定過程中應予地方政 府充分之參與，俾利維繫地方自治團體自我負責之機制。行政主管機關草擬此類法律，應與地方政府協商，並視對其財政影響程度，賦予適當之參與地位，以避免有 片面決策可能造成之不合理情形，且應就法案實施所需財源，於事前妥為規劃，自應遵守財政收支劃分法第三十八條之一之規定。立法機關於修訂相關法律時，應予地方政府人員列席此類立法程序表示意見之機會。

J. Y. Interpretation No.   550
Date：2002.10.4
Issue：Is the provision of the National Health Insurance Act constitutional in requiring that local governments contribute to the subsidy for premium payable by people residing in their respective administrative regions for the national health insurance program executed by the central government?

Holding：
In order to promote social welfare, the State shall establish a social insurance program, and to improve national health the State shall develop extensive services for sanitation and health care and a system of public medical service. These are explicitly provided in Articles 155 and 157 of the Constitution. Furthermore, Article 10 of the Amendments to the Constitution requires in Paragraphs 5 and 8 thereof that the State shall promote the national health insurance and pay special attention to social welfare activities such as social relief and aid, welfare services, social insurance, and medical and health care. The duty of the State to promote the national health insurance rests on governments at both the central and the local levels. It is also set forth in the Constitution that each local self-governing body shall assume the duty to carry out activities in connection with sanitation, charity and public welfare for the purpose of taking care of the livelihood of the people residing within its respective administration region, and that such activities may be partly carried out through the implementation of the national health insurance program. The National Health Insurance Act promulgated on August 9, 1994, and coming into force as of March 1, 1995, is a statute enacted and executed by the central government. All administrative expenditure arising out of and in connection with the implementation of the national health insurance program must therefore be borne by the central government. However, the insurance premium at issue here, which each local self-governing body is bound to subsidize under Article 27 of the Act, is a payment made by the insured subjects as a consideration for obtaining protection rather than cost and expenses for the implementation of the national health insurance program. It is thus consistent with the purpose contemplated by the constitutional provision cited above that each local government makes a contribution to part of the subsidy for such premium in addition to the portion borne by employers and subsidized by the central government.

　　While local self-governing bodies are protected by the constitutional system, and the availability of funds required for their administration is a matter within the scope of their self-governing financial power subject to the principle of legal reservation, the Constitution does not forbid the central government from requiring under law that local governments, which have the duty to act in concert in matters relating to the national health insurance program, share the subsidy for the premium insofar as such requirement is necessary for the overall administration of the State and to the extent that the core realm of their self-governing power is not encroached upon. The Constitution is silent in respect of the sharing of financial responsibility for matters undertaken by the central and local governments. While it is provided in the Act Governing the Allocation of Government Revenues and Expenditures, Article 37, Paragraph 1, Subparagraph 1, that expenditure of governments at all levels for matters implemented by the central government under laws enacted thereby shall be borne by the central government, the provision is not intended to mean only expenditure for administration matters, and we see no reason to preclude the making of special law so long as it meets the foregoing conditions. With this concept in mind, we hold that Article 27 of the National Health Insurance Act comes under such a special law. As regards the ratio of subsidy specified in said article to be allotted to different classes of insured persons for their premium payment, it is a matter within the scope of legislative discretion and gives rise to no question of constitutionality unless such ratio is clearly inappropriate and unreasonable.

　　Where local self-governing bodies are required to share the cost for the implementation of any law such as the provision in respect of the ratio of subsidy for the premium at issue as set forth under the National Health Insurance Act, Article 27, Subparagraph 1, Items 1 and 2, and Subparagraphs 2, 3 and 5, they must be given sufficient opportunity of participation in the course of formulation of the law. For this purpose, the competent administrative agency must discuss and consult with local governments when drafting such law to avoid possible unreasonable outcome, which may result from arbitrary decisions, and must work out sound preplanning of the financial resources required for the implementation of the law. Likewise, the legislature, in revising relevant laws, must allow representatives of local governments the opportunities to be present as observers during the legislative process and to express their opinions.

Reasoning：
In order to promote social welfare, the State shall establish a social insurance program, and to improve national health the State shall develop extensive services for sanitation and health care and a system of public medical service. Furthermore, the State shall promote the national health insurance and pay special attention to social welfare activities such as social relief and aid, welfare services, people's employment, social insurance, and medical and health care. Expenditure for relief activities such as social relief and aid and people's employment must be given priority when preparing the national budget. These are the fundamental policies of the State explicitly laid down in Articles 155 and 157 of the Constitution and Article 10, Paragraphs 5 and 8, of the Amendments to the Constitution. While the term "State" is used in the text of a number of articles in the Constitution, whether it should be interpreted to refer solely to the central government or to include both central and local governments depends on the nature of the matter prescribed by the particular provision, and should not be generalized. The constitutional provisions relating to the fundamental policies of the State are intended to be guiding principles directed at the formulation of national policies and overall development of the nation, and must thus operate to regulate not only the central level of the government. Article 155 of the Constitution requiring that the State establish a social insurance program to promote social welfare is designed to make the implementation of a social insurance program a primary means whereby the goals of social welfare may be achieved. And social welfare activities reflect the duty of the State to take care of its people by offering them a decent life. This duty must be undertaken not only by the central government but also in concert by local self-governing bodies, which are even more closely related to the lives of the people residing in their respective regions (See the Local Government Systems Act, Article 18, Subparagraph 3, Item 3) and should not be considered free of any duty to work with the central government in concerted efforts to make the fundamental policies relating to social security a reality. It follows therefore that the duty of the State to put forward a national health insurance program rests on both the central and the local governments. The National Health Insurance Act promulgated on August 9, 1994, and coming into force as of March 1, 1995, is a statute enacted and executed by the central government. Under Article 68 of the Act which provides that all costs and expenses for facilities, equipment and working funds (including personnel costs and management expenses) necessary for the national health insurance program shall be paid by the central government; thus, the administrative expenditure arising out of and in connection with the implementation of the national health insurance program must therefore be borne by the central government. However, it is provided by the Constitution in Article 109, Paragraph 1, Subparagraphs 1 and 11, and Article 110, Paragraph 1, Subparagraphs 1 and 10, that local self-governing bodies shall have the duty to carry out activities in connection with sanitation, charity and public welfare for the purpose of taking care of the livelihood of the people residing within their respective administration regions. While such duty may be partly fulfilled through the implementation of the national health insurance program, it is not discharged by the implementation of the program. The insurance premium at issue here, which each local self-governing body is bound to subsidize at a specified rate under Article 27 of the Act, is a payment made by the insured subjects as a consideration for obtaining protection and as the financial resources for insurance payment rather than cost and expenses for the implementation of the national health insurance program. It is thus consistent with the purpose contemplated by the constitutional provisions cited above that all local governments join with the central government in establishing a social security system by subsidizing a part of the premium in addition to the portion borne by employers and subsidized by the central government. This was also what we had in mind in deciding our Interpretation No. 279 in which we held that the subsidy granted by a provincial or municipal government as a contribution to the premium for labor insurance constituted the performance of such government's duty in respect to workers’ welfare.

　　While local self-governing bodies are protected by the constitutional system, and the availability of funds required for their administration is a matter within the scope of their self-governing financial power subject to the principle of legal reservation, the Constitution does not forbid the central government from requiring under law that local governments share the subsidy to the premium insofar as such requirement is necessary for the overall administration of the State and to the extent that the core realm of their self-governing power is not encroached upon. By "encroachment upon the core realm" we mean jeopardy to the essence of the autonomous power of local self-governing bodies to such an extent that the protection guarding the system of local self-governing bodies becomes fictional. This includes preparation of budgets by the central government for and on behalf of local governments and the requirement that local governments share expenses for matters totally unrelated with the duty and functions of local governments such as foreign affairs and national defense. Where local self-governing bodies are required by law to assume the duty to lend concerted efforts in the division of powers or to share expenditure for matters related with the essence of self-government, we do not believe the core realm of their self-governing financial powers is being jeopardized. The Constitution is silent in respect of the sharing of financial responsibility for matters undertaken by the central and local governments. While it is provided in the Act Governing the Allocation of Government Revenues and Expenditures, Article 37, Paragraph 1, Subparagraph 1, that expenditure of governments at all levels for matters implemented by the central government under laws enacted thereby shall be borne by the central government, the provision is not intended to mean only expenditure for administration matters. For this purpose, special provisions may be made in order to define the sharing of financial responsibilities so long as the law meets the foregoing conditions, more so in view of the provision of the Act in Schedule 2-III whereby "subsidy and expenditure for social insurance, social relief and aid, social welfare, people's employment, medical and health care, and other activities" are listed under category 10 "social welfare expenditure of municipalities under direct jurisdiction of the Executive Yuan." Undoubtedly, the issue here with respect to Article 27 of the National Health Insurance Act has to do with such special legislation, and the items of expenditure in question come under the category specified in Schedule 2 of the Act Governing the Allocation of Government Revenues and Expenditures. As regards the ratio of subsidy specified in said article to be allotted to different classes of the insured for their premium payment, it is a matter within the scope of legislative discretion and gives rise to no question of constitutionality unless such ratio is clearly inappropriate and unreasonable.

　　Where local self-governing bodies are required to share the cost and expenses for the implementation of any law such as the provision in respect of the ratio of subsidy for the premium at issue as set forth under the National Health Insurance Act, Article 27, Subparagraph 1, Items 1 and 2, and Subparagraphs 2, 3 and 5, they must be given sufficient opportunity for participation in the course of formulation of the law in order to preserve the self-responsible mechanism of local self governing bodies. For this purpose, the competent administrative agency, when drafting such law, must discuss and consult with local governments and allow them reasonable opportunity of participation in light of the possible impact of the law on their financial conditions, so as to avoid possible unreasonable outcomes, which may result from arbitrary decisions, and must work out sound preplanning of the financial resources required for the implementation of the law under Article 38-1 of the Act Governing the Allocation of Government Revenues and Expenditures. Likewise, the legislature, in revising relevant laws, must allow representatives of local governments the opportunities to be present as observers during the legislative process and to express their opinions.

' Translated by Raymond T. Chu.