【作者】 周玉萍；

【导师】 魏华林；

【作者基本信息】 武汉大学 ， 金融学， 2013， 博士

【摘要】 健康是每个个体,也是社会共同追求的重要目标。健康保险是处置健康风险的重要手段,也是民众幸福指数构成的核心内容。当前,与追求健康目标直接相关的健康保险制度改革正在成为众多国家重要政策目标之一。健康的实现主要依赖政府安排,还是得益于个人努力,或者是将政府安排与个人努力结合起来?不同的选择可能形成不同的实现路径。2009年4月,以《中共中央国务院关于深化医药卫生体制改革意见》公布为标志的“新医改”的启动,2012年8月,以国家卫生部等六部委《关于开展城乡居民大病保险工作的指导意见》联合下发为标志的“大病医保”的实施,中国政府已经释放了比较明显的信号,在切实承担政府在健康保险制度建设主导力量的同时,更要通过有效整合政府与市场的力量共同推进这一制度的完善。正是在这一背景下,本文选择以中国健康保险制度研究为题,并以政府与市场结合的改革方向为重点,探讨转型时期健康这一基本需求如何得到更好地解决和落实。这也是本文的出发点和研究目的。围绕“中国健康保险制度研究”这一主题,本文运用文献研究、比较研究和历史研究等方法,以健康经济学理论、健康保障资源配置理论、公共产品供给主体理论和健康保障的社会公平理论等为分析框架和理论基础,阐释了中国健康保险制度的发展历程、发展困境和改革方向等三大核心内容。在行文架构上,本文主体部分有五章,具体包括健康保险制度的理论探源、健康保险制度的历史变迁、中国健康保险制度的发展实践和困境、健康保险制度的国别比较以及中国健康保险制度的改革方向。1、关于健康保险制度的发展历程。本文从世界和中国两个角度对健康保险制度的历史进行了回顾。从世界看,健康保险制度经历了疾病保险、医疗保险、改革调整,目前确立了多层次医疗保障体系的发展方向,在制度模式、健康筹资以及实施方式等方面都具有鲜明特征,“政府主导-市场补充”是现阶段中国健康保险制度的最重要的特色。2、关于中国健康保险制度的发展困境。在六十多年的发展探索中,“政府主导”是推动中国健康保险制度变迁的原动力,这种主导力量不仅体现在宏观层面“自上而下”的改革推动和制度设计上,也体现在微观层面的市场管理和准入限制等方面。但是,不管是有意为之还是历史必然,制度变迁中,市场力量从无到有,从弱到强,成为健康保险制度的重要组成部分。在两种力量的共同作用下,目前政府主导下适度市场化的健康保险制度模式正在逐步形成中。但是事实上,在“政府主导-市场补充”模式下,政府退出竞争性领域,主动为市场发展提供环境的意愿并不强烈；而市场化的商业健康保险,由于缺乏切实有效的政策支持等原因,发展受到抑制。也正因为这样,当前中国健康保险制度建设总体成效不尽人意,存在明显缺陷,主要是：公平性不足、持续性待考量、健康风险有效分担不足。3、关于中国健康保险制度改革方向。当前世界上主要健康保险制度模式有以美国为代表的市场机制模式、以英国为代表政府机制模式以及以德国为代表的社会医疗保险模式,在对上述三种模式进行比较的基础上,本文认为：一国健康保险制度模式的选择,受诸多因素影响,取决于政府意志,更深层面也与各国的文化积淀、经济基础、发展环境等因素息息相关；并且任何一种相对健全的健康保险制度,基本上都是各种类型的模式,如公共医疗福利、社会医疗保险、民间医疗慈善、商业健康保险等相互组合而成。借鉴国际经验,中国健康保险制度改革,在发展目标上,应建立“人人享有健康”这一普适性目标,这既是国际发展的趋势、也是健康观念转变的需要、更是当前建设人力资本强国的必然要求；在政府与市场的关系上,要积极推进政府与市场结合的发展,通过政府健康保障部分责任直接让渡给市场机构、市场机构参与政府健康保障事务、政府健康保障服务机构的市场化改革等三种方式,充分发挥市场的作用；在价值评价上,要既注重公平,又注重效率,努力实现公平与效率的均衡,并通过厘清政府与市场在健康保险制度体系建设中的边界、充分发挥商业健康保险的作用和功能,提升健康保险制度价值。通过上述内容的阐释,本文得出的主要结论是：(1)政府与市场及其关系在健康保险制度发展中至关重要。在健康保险从疾病保险到医疗保险到健康管理的不同发展阶段中,伴随民众健康观念的转变、经济发展以及科技进步,政府的介入与市场的推动是其发展的重要力量。(2)现阶段中国健康保险制度由“政府主导-市场补充”向政府与市场结合转变非常必要。中国健康保险制度在六十多年中的探索中,经过了重政府——重市场——政府主导下的适度的市场化发展的三个阶段,这种改革调整也说明试图用某种单一手段或方式,建立真正统一、和谐、有效的中国健康保险制度的任务相当艰巨。当前在“政府主导”的下,市场化发展受到明显压制,从而使中国健康保险制度在公平性、持续性以及风险分担等方面存在明显的不足,因而必须明确政府和市场的边界,推动健康保险制度政府与市场的有效结合。(3)在借鉴国际经验的基础上,构建了中国政府与市场结合的健康保险制度的目标定位、结合的方式路径以及价值评价指标体系。在改革方向从发展目标上,中国健康保险制度应从“人人享有基本医疗卫生服务”转向“人人享有健康”这一普适性目标；在政府与市场的关系上,要积极推进政府与市场结合的发展；在价值评价上,要既注重公平,又注重效率,努力实现公平与效率的均衡。更多还原

【Abstract】 Health is an important objective for individuals and society as a whole. Health insurance, an important way to deal with health risks, is an essential part in the happiness index. Nowadays, the reform of health insurance system central to our pursuit of health has become an important policy objective in many countries. Does the achievement of health depend heavily on government’s arrangement, or citizen’s endeavor, or the combination of these two factors? Different choices probably determine different pathways. In April,2009, Chinese government launched a new medical and healthcare reform by issuing "CCCP and the State Council’s Guidelines about How to Deepen the Medical and Healthcare Reform"; in August2012, the Ministry of Health and other five Ministries and Commissions issued "Guidelines about How to Implement Critical Illness Insurance for Urban and Rural Citizens". Thus Chinese government have sent a clear signal that while the Government will direct the development of health insurance system, it will also incorporate the forces of market to implement the system together. In this context, this dissertation chooses the topic of China’s health insurance system. It will focus on the direction of reform, i.e., the combination of government and market, and discuss how the basic demand of health could be met and implemented.I will use literature review, comparative study and historical study to deal with the subject. My analytical framework and theoretical foundations include, not confined to, health economics, health resources allocation theory, public goods supplier theory, and social equality of healthcare. I will focus on three major topics: the development of China’s health insurance system, its difficulties, and the direction for reform. The dissertation is divided into five chapters:theoretical analysis of health insurance system, historical development of health insurance system, practice and difficulty of China’s health insurance system, internal comparison of health insurance system, direction for China’s health insurance system reform.1. Historical Development of Health Insurance SystemI will review the history of health insurance system in China and in the world as well. Globally, the health insurance system underwent three stages:disease insurance, medical care insurance, health management. There are three features worthy of special attention. First, two transitions, one from disease insurance to medical care insurance, the other one from disease insurance to health management, bring about the fundamental change in the scope and nature of health insurance. Second, the formation of social insurance system with government involvement leads to a more sophisticated health insurance system and helps it more perfect and mature. Third, the crisis in the health insurance system in Western countries triggers the development of market mechanism for health insurance system. In China, health insurance system is developed in the context of economic transition, transformation of government functions, and market-oriented reform; it went from national welfare in the early years of PRC, to reformative adjustment in the process of economic institution transitions, finally to the nowadays direction for development of multi-level medical and healthcare system. China’s health insurance system has distinguishing features in three dimensions of system pattern, health financing, and implement pathways. Its most important feature is that it is a system led by government and supplemented by market.2. Difficulty of China’s Health Insurance SystemIn more than sixty years of development and exploration, leading by government is the drive of China’s health insurance system, evident both in the from top to down macro-level of reform motivation and system design and in the micro-level of market management and access regulation. However, market forces has emerged from nowhere and has grown stronger, becoming an essential part of health insurance system. In the combinative action of these two forces, the health insurance system has developed toward a system led by government and modestly supplemented by market. But in this pattern, the government is reluctant to exit from competitive industry and leave room for market. And market-oriented commercial health insurance has been suppressed due to the lack of efficacious support from government’s policies. Today, China’s health insurance system is not satisfactory and has some blatant weaknesses:inequality, unsustainable development, the lack of resilience in the health risk sharing.3. Direction for China’s Health Insurance System ReformI will compare three major health insurance systems in the world, which are American market-oriented pattern, Britain’s government-led pattern, and Germany’s social medical insurance pattern. I will demonstrate the following propositions:The choice of health insurance institution in a country is determined by several factors, including not only government will, but also cultural sediment, economic power, and development of the country; Any relatively sound health insurance system is a combination of several patterns, which include public medical welfare, social medical care insurance, civilian medical philanthropy, and commercial health insurance; For objective:the general objective of China’s health insurance system should be "Everyone Enjoys Health", which is global current, is necessary for the change in health thinking, and is required for building a country with strong human capital.For the relation between government and market:For the development of combination of government and market, the government should turn some health care responsibility to market institutions, market institutions should participate in the health care task led by government, and the government health care services should be underwent the market reform. In this connection, market should be allowed to play an important role.For value and assessment:We should value equality and efficiency as well, attempting to maintain an equilibrium of equality and efficiency. By delimiting the boundary between government and market in the development of health insurance system, we should let commercial health insurance play a full role and increase the value of health insurance system.The major conclusions of this dissertation are:1. The relation between government and market is very important in the development of health insurance system. The participation of government and the drive of market play important roles in the development of health insurance from disease insurance to medical insurance and then to health management.2. The transition of health insurance system from the institution led-by government and supplemented by market to the institution with a combination of government and market is sorely needed.3. The objective of health insurance system should be "Everyone Enjoys Health", not merely "Everyone Has Basic Medical and Health Care Service"; it is important to combine the government and market as far as the relation between government and market is concerned; and our value should be placed on the equality and efficiency as well.更多还原