【作者】 奎潮；

【导师】 朱铭来；

【作者基本信息】 南开大学 ， 保险学， 2012， 博士

【摘要】 医疗保险是正在进行中的深化医药卫生体制改革的重要一环。无论是在医药卫生体制改革的长期目标——建设四大体系，还是在短期目标——推进五项改革中，医疗保险始终占据着核心的地位。近十年来，我国医疗保险的建设发展迅速。截至2011年底，基本医疗保险参保人数超过13亿人，覆盖率达到95%。与此同时，我国的商业医疗保险也在快速发展，2011年底，商业医保的保费收入达到691.7亿元。从经济学角度看，发展医疗保险对于转变经济发展方式，促进民生事业都有着积极的现实意义。医疗保险的经济社会效应至少体现在以下两个方面：一是通过解除老百姓对于因病致贫，因病返贫的担忧，稳定居民的收入预期，释放消费需求，提振内需。二是提升国民健康水平和劳动生产率，提高国民的人力资本。因此，建立覆盖城乡的医疗保险体系是实现经济可持续发展的切实举措。但是，由于信息不对称和政府失灵的存在，依靠单一的医疗保险形式难以“包打天下”，必须走基本医保、商业医保和补充医保多种形式并存的“双轨制”乃至于“多轨制”，各种保险形式之间通过竞争提高效率，通过合作互补劣势，才能保证整个医疗保险市场在公平和效率之间维持稳定。本文致力于研究医疗保险制度的经济社会效应和运营模式。首先，本文从理论角度归纳总结了医疗保险对于预防性储蓄和健康人力资本的作用，并通过对我国省级面板数据和第四次卫生总调查数据的实证分析，考察医疗保险制度的经济社会效应在我国的体现程度。然后，本文对国际上具有代表性的医疗保险制度进行比较分析，再通过理论的总结和各国实践中积累下的经验，探讨我国医疗保险制度具体运营模式，并结合我国医疗保险现阶段的特点提出下一步的改进建议。本文分为七章。除第一章导言外，其他部分的安排如下：第二部分是文献综述。本章对于医疗保险与消费理论，医疗保险与人力资本理论以及基本医保和商业医保关系定位进行了归纳总结，介绍了世界范围内在这三个领域具有影响力的理论文献和实证文献。第三部分是国际经验借鉴。介绍了美国、德国、英国的医疗保险制度。包括各国医疗保险模式产生的历史条件、发展历程、存在问题及改革趋势，各国公费医疗或社会保险的覆盖范围、政府财政投入、个人及单位缴费比例、对医疗费用增长的管控力度、医疗费用自负比例等。第四部分是医疗保险的经济社会效应——对于消费需求影响的实证研究。首先回顾了我国医疗保险体系的发展历程和居民消费的发展历程，之后使用我国31个省、自治区、直辖市的面板数据，建立了城镇职工、城镇居民、新农合和商业医保四个模型研究我国医疗保险对居民消费的影响，实证结果发现：在城市中，四种保险对于居民消费都具有明显的促进作用。第五部分是医疗保险的经济社会效应——对于健康水平影响的实证研究。首先回顾了我国国民健康情况的发展历程和现阶段呈现出的特点，之后采用第四次国家卫生服务总调查的数据，分别检验城镇居民、新农合、城镇职工保险对居民健康的影响。研究发现，城镇居民医疗保险对居民健康水平的提升作用最为明显。第六部分是医疗保险体系模式优化探讨。在推广医疗保险制度的过程中，有一个重要的问题需要予以明确：商业医疗保险和社会医疗保险的关系如何定位。从国际经验来看，很多国家医疗保险制度都采取了商业医保和社会医保“双轨制”，制度的难点和特色也在于如何安排商业医保和社会医保的角色分工，这个问题的实质是对政府和市场权力边界的划分。本部分以保险经济学为基础，结合国际国内实践，对社会保险和商业保险“双轨制”存在的合理性进行探析，并根据我国的现状探讨了二者匹配方式并提出框架性建议。第七部分是政策建议。对于前面的论点进行总结，并就我国医疗保险制度改革的具体原则方向给出建议。包括确定基本医疗保险下一步的发展重点，商业医疗保险和社会医疗保险的合理分工、商业医疗保险参与基本医疗保险经营的主要方式等等。更多还原

【Abstract】 Medical insurance plays an important role in further reform of medicine andhealth system. Both on the long-term objective of medicine and health system reform,namely as four system establishment, and on the short-term objective, namely aspromoting the five reforms, medical insurance occupys an important position. In therecent ten years, the development of the national medical insurance system changedrapidly. By the end of2011, the number of people participating in basic medicalinsurance surpasses1.3billion, with the coverage of95percent. At the same time,the commercial medical insurance achieves good results. By the end of2011, thepremium income of commercial medical insurance accounts to69.17billion Yuan.From the perspective of economics, the development of the medical insurancereflects a positive and realistic significance for the transformation of the mode ofeconomic development and promotion of people’s livelihood. The economic andsocial benefits of medical insurance are at least embodied in the following twoaspects: on one hand, stabilizing the expected income of residents, releasingconsumption demands and motivating domestic demands by casting off the worries ofbeing into poverty because of illness; on the other hand, elevating national health,labor productivity and human capital of the residents. Therefore, the establishment ofmedical insurance system covering urban and rural is an effective means of realizingthe sustainable economic development. However, we can’t just develop a singlemodel of health insurance for information asymmetry and government failure, Wemust develop various forms of medical insurance, including basic medical insurance,commercial medical insurance and complementary medical insurance, etc. Theefficiency can be upgraded by the competition between different insurance modes,and it will remedy the defect to each other by cooperation to ensure the stabilizationof the whole medical insurance market between justice and efficiency.This paper is dedicated to the researches on economic and social benefits andoperational modes of medical insurance system. Firstly, we summarizes the effects of medical insurance on precautionary savings and health human capital from thetheoretical perspective,then we makes empirical analysis by using the regional paneldata and the survey data from the National Health Services Survey. Secondly, wemakes the comparative analysis of the typical international medical insurance system,explores concrete operational modes of medical insurance system of our country bytheoretical summary and practical experience of other countries and puts forwardfurther improvements by combining the characteristics of medical insurance systemof our country at current stage.This article is divided into seven chapters, besides the first chapter isintroduction, the other six chapters are as follows:The second part is the literature review. This paper introduces the literaturesfocusing on the following areas: the theory of the relationship between medicalinsurance and consumption, the theory of the relationship between medical insuranceand national health, the theory of the relationship between basic medical insuranceand commercial insurance. We introduce the theoretical and empirical thesis withgreat effects in these three fields worldwide.The third part is the international experience. We introduce the medicalinsurance system of the United States, Germany and United Kingdom, including thehistorical background, development processes, reform trends, the coverage of socialmedical insurance and commercial medical insurance, government financial support,personal or unit payment proportion, self-paying proportion, etc. of these countries.The fourth part is the empirical analysis of the effect of medical insurance onconsumption demand. After reviewing the development processes of national medicalinsurance system and resident consumption, we establish four modes including themodel of urban residents’ basic medical insurance, the model of new ruralcooperative medical insurance, the model of urban workers’ basic medical insuranceand the model of commercial medical insurance to analyze the effects of medicalinsurance on resident consumption. The data we used in these models is the paneldata of the31provinces, autonomous regions inhabited by minorities, andmunicipalities directly under the supervision of the central government in China. Theempirical results show that the medical insurance obviously stimulates resident consumption. However, the consumption stimulation of urban resident medicalinsurance is greater than that of new rural cooperative medical insurance and theconsumption stimulation of commercial medical insurance is greater than that ofurban workers’ basic medical insurance.The fifth part is the empirical analysis of the effect of medical insurance onnational health. After the retrospection of the development process of the nationalhealth condition and characteristics of current stage, we inspect the effect of basicmedical insurance on the national health level in China by using the data from theFourth National Health Services Survey. We found that the urban residents’ medicalinsurance has positive effects on national health.The sixth part is the discussion of the medical insurance operation mode. In theprocess of promoting medical insurance system, a considerable problem is needed tobe clear: the location of the relationship between commercial medical insurance andsocial medical insurance. From international experience, medical insurance systemsof many countries adopt “double-track system”. The difficult points of this system isthe role division arrangement of commercial medical insurance and social medicalinsurance, the nature of the problem is the power division of government and market.Based on economics of insurance and the experience at home and abroad, weexplores the rationality of the existence of “double-track system” in China and putsforward suggestions according to the current condition of our country.The seventh part is the policy proposal. Firstly, we summarize the views comingfrom the former researches. Then, we put forward some advices on the direction ofthe next stage of medical insurance reform, including confirming the focus ofdevelopment of basic medical insurance, rational division of commercial medicalinsurance and social medical insurance, etc.更多还原