【作者】 陈妍；

【导师】 朱铭来；

【作者基本信息】 南开大学 ， 保险学， 2012， 博士

【摘要】 公共医疗保障基金是由政府或社会组建的为其成员提供医疗卫生支出保障的基金。各国公共医疗保障基金的形式和称谓有所不同，常见的有“社会医疗保险基金”、“法定医疗保险基金”、“国民医疗保险基金”、“社区互助医疗保障基金”、“协会医疗自保基金”等。在我国，公共医疗保障基金是指城镇职工基本医疗保险、城镇居民基本医疗保险和新型农村合作医疗项目形成的统筹基金。近年来，我国公共医疗保障基金在覆盖面和保障水平上都取得了突破性的进展，但也存在一些问题。比如对贫困人口没有实现保障的全覆盖；以工资作为缴费基数有违筹资公平；城镇居民基本医疗保险和新型农村合作医疗缺乏稳定的筹资增长机制；横向平衡的缴费率不利于应对人口老龄化和医疗费用增长等。本文从筹资模式、筹资水平和筹资分担方式三个角度，研究公共医疗保障基金的筹资机制设置，意在使之能够适应基金覆盖面的扩大和保障水平的提高，应对人口老龄化和医疗费用增长等长期风险，并且更加符合效率和公平原则。本文首先从财政学、发展经济学、新制度经济学等基本理论入手，论证公共医疗保障基金的基本性质、筹资的公平和效率要求以及公共医疗保障基金筹资机制演进的规律等。在筹资模式部分，对九个代表性国家的公共医疗保障基金筹资模式进行了深入细致的横向比较，并结合我国的经济、社会、文化特点，论证了我国的公共医疗保障基金可选择的筹资模式。在筹资水平部分，运用短期聚合风险模型和生命表方法，测算了全民医疗保障条件下，我国公共医疗保障基金未来三十年的筹资需求，以及按照现行筹资机制，基金在未来三十年可以达到的筹资水平，比较两者之间的缺口，同时以X市为例，采用个体医疗费用数据，建立基金长期收支风险预测模型。在筹资分担方式部分，依据前几章的理论观点和实证研究，提出公共医疗保障基金的筹资分担方案，并采用横向平衡和综合平衡两种费率厘定方法，测算各缴费主体的适当缴费率、缴费额度以及政府财政的合理补贴金额。最后，从法律建设、运营管理和并行制度的角度，论述了公共医疗保障基金筹资机制调整所需要的配套改革。本文测算结果表明，假设全部人口参保，保障水平达到70%，按照目前的医疗费用增长速度和人口年龄变化情况，现行政策下的筹资水平不能满足筹资需求。如果城镇居民基本医疗保险和新型农村合作医疗的缴费和财政补贴能够持续快速增长，筹资水平可以在预测期中期赶上筹资需求，但是随着人口老龄化和医疗费用的进一步增长，筹资需求又会重新超过筹资水平。可见现行的筹资政策是需要调整的。如果所有人参保人以收入为基数按同样比例缴费，则横向平衡缴费率从2011年的6.02%逐渐增加到2040年8.35%，综合平衡费率从2011年到2040年为8%。横向平衡缴费率情况下，政府补贴总额从2011年的2698.43亿元逐渐上升到2031年的4602.45亿元，然后逐渐下降到2040年的1930.55亿元；综合平衡费率情况下，政府补贴总额从2011年的4057.54亿元逐渐增加到2024年的5500.33亿元，然后逐渐下降到2040年的1849.16亿元。与现行政策相比，新筹资模式中城镇参保人的缴费率有所提高，但是仍然低于国际通行的缴费水平，农村参保人的缴费水平也有所提高，但提高的幅度低于城镇参保人，财政补贴的幅度则会大大降低，更重要的是，新筹资模式的整体筹资水平可以满足全民参保和保障水平70%的筹资需求，并且可以应对人口老龄化和医疗费用增长的趋势。本文还提出两套备选的筹资方案，农村参保人按照家庭所拥有的生产资料缴费，二是所有参保人以家庭为单位参保缴费，在横向平衡假设下，前者每个缴费点对应的金额由2011年的4.34元增长到2040年的6.20元，后者城镇家庭就业人员应缴保费率从2011年的5.97%上升到2040年的9.61%。本文的基本结论和核心观点有以下五点。第一，公共医疗保障基金筹资不应仅以工资收入为基数，这样不仅局限了筹资来源，也违背了筹资公平，并且不利于城乡缴费政策的统一，应当将筹资基数扩大到全部收入。第二，比较合适的缴费机制是比例缴费，让基金筹资给所有参保人带来的经济负担相同。缴费基数上限的设置增加了基金筹资的累退性，可以由政府总额补贴取代。第三，政府有义务确保全民，尤其是全部低收入人群享有公共医疗保障。对于经济特别困难的人群，应当由政府代缴保费。第四，人口老龄化会给公共医疗保障基金的长期收支平衡带来风险，可以在部分积累假设下，厘定综合平衡费率。除此之外，还需要定期对基金的风险状况进行即时评估，向参保人公布基金财务和风险状况的完整报告。第五，用针对消费、流转以及企业所得征收的特种税收来补充公共医疗保障基金有利于减少基金筹资对居民收入增长的依赖，分散基金筹资风险。更多还原

【Abstract】 Public Health Insurance Fund is a non-profit fund organized by government orsociety to provide health expense coverage for its members. It has various forms indifferent countries, such as “Social Health Insurance Fund”,“Statutory HealthInsurance Fund”,“National Health Insurance Fund”,“Community-based HealthInsurance Fund”,“Society Managed Health Insurance Fund” etc. In China, it refers tothe pooling fund of the social medical insurance, which consists of the UrbanEmployees Basic Medical Insurance, the Urban Residents Basic Medical Insurance,and the New Rural Cooperative Medical Schemes.In these years, the Public Health Insurance Fund in China has achieved abreakthrough in extending coverage and increasing benefit, while many problems stillexist in the system. Some residents below the poverty line are not covered by the fund;contribution based on the working salary instead of the overall income violates theequity principle; the funding of the Urban Residents Basic Medical Insurance and theNew Rural Cooperative Medical Schemes lacks of a steady growth mechanism; theratemaking scheme on the annual balance basis is vulnerable confronting withpopulation ageing and rapid increase of medical costs….The funding mechanism isstudied from three aspects in this research: the funding pattern, the funding level andthe distribution of funding responsibility. The aim of the research is to make someproper recommendation on the adjustment of the Public Health Insurance fundingscheme, to make it more stable in coping with enlarged coverage and enhancedbenefit, more adaptable in face of population ageing and cost increasing, and morereliable in balance between equity and efficiency.In the first part of the research, the theoretical framework is built using the basictheories in public finance, development economics, new institutional economics etc.,mainly about the essential characteristics of the Public Health Insurance funding, theprinciples of equity and efficiency, and the regular evolution pattern of Public HealthInsurance Fund. In the second part, funding patterns of the typical Public HealthInsurance Funds in nine different countries are analyzed and compared, in order to borrow ideas and draw lessons for the funding pattern design of the Public HealthInsurance in our country. In the third part, short term aggregate risk model andlife-table method are used to calculate the funding demand of the Public HealthInsurance in our country in next30years under universal coverage, and the fundingcapacity in the same period under present policy, to measure the gap between them. Along-term financial risk model for the Public Health Insurance Fund is also builtusing the micro-data of individual medical costs, taking city X as an example. In thefourth part, new proposals to distribute funding responsibility are set up based on thetheoretical foundation proved before. Contribution rates are calculated on both theannual balance basis and the comprehensive balance basis, adequate fiscal subsidyamounts are assessed at the same time. Last, some coordinated reforms required inthe adjustment of Public Health Insurance funding are discussed, including thereforms in legal system, administration and some parallel mechanisms.The calculation result illustrates, if the Public Health Insurance Fund covers thewhole population with the benefit level of70%, and if the population ageing andmedical costs increasing as rapid as assumed, the funding capability under presentpolicy is not sufficient. If the contribution and fiscal subsidy of the Urban ResidentsBasic Medical Insurance and the New Rural Cooperative Medical Schemes increaserapid enough, the funding capacity would match the demand in the mid-term of theforecast-period, while after that, the funding demand would exceed the fundingcapacity again due to population ageing and medical costs increasing. Thus thepresent funding policy ought to be adjusted. If the contribution is determined inaccordance with overall income, and the contribution rate is uniform, the annualbalance contribution rate would be6.02%in2011and increase gradually to8.35%in2040, the comprehensive balance contribution rate would be8%from2011through2040. In the annual balance condition, the fiscal subsidy amount would be269.84billion Yuan in2011, raise to460.25billion Yuan in2031and drop to193.06billionYuan in2040. In the comprehensive balance condition, the fiscal subsidy amountwould be405.75billion Yuan in2011, raise to550.03billion Yuan in2024and dropto184.92billion Yuan in2040. Comparing with the present scheme, the contributionrate for the urban employees and residents in the new scheme would be higher, yet itwould still be lower than the international level; the contribution of the rural population raised likewise though not as much as the urban section; the fiscal subsidywould be lower than in the present scheme. Most significant point is that the fundingcapacity in new scheme is sufficient for universal coverage and70%benefit leveleven confronting the population ageing and the increase of medical costs. Anothertwo funding schemes are proposed in the research, in the first one, rural populationcontribute on the basis of their capital goods, such as lands, orchard, fishingpool...owned by a family; in the second, all the population enrolled the fund in familyunit. In the annual balance hypothesis, rural population would contribute4.34Yuanfor each contribution point in2011and6.20Yuan for each contribution point in2040in the first scheme, employees in urban families would contribute5.97%of theirincome in2011and9.61%of their income in2040.There are five major conclusions in the research. First, the base of thecontribution ratemaking should be extended from the working salary to the overallincome; otherwise the funding mechanism is not equitable. When the funding policyfor urban and rural population is converging, there should be a unified basis forcalculating the contribution. Second, the advisable contribution mechanism isproportional, that is, the economic burden brought by the contribution is equal toeveryone. The upper limit for the contribution basis makes the funding processregressive. It could be substituted by a lump-sum subsidy for the general tax. Third,the government is responsible for ensure everyone be covered in Public HealthInsurance Fund, especially those under poverty line, whose contribution should bepaid by the social welfare department. Fourth, the long-term financial status of PublicHealth is challenged by the population ageing. Ratemaking system based on partialaccumulation could counteract the ageing effect. Besides, there should be a financialrisk warning system. The management of the Fund should evaluate the financial riskof the fund each year, and publish intact report on the financial status of the Fundregularly to the enrolled population. Finally, taxes on consumption, value-added andenterprise income etc. could be utilized to supplement the Public Health InsuranceFund, so that the financial risk of the fund could be dispersed.更多还原