【作者】 夏芹；

【导师】 尹爱田；

【作者基本信息】 山东大学 ， 社会医学与卫生事业管理， 2010， 博士

【摘要】 研究背景新医改方案提出要建立健全覆盖城乡居民的基本医疗保障体系,实现人人享有基本医疗保障的目标,旨在通过城镇职工基本医疗保险、新型农村合作医疗制度(以下简称新农合)、城镇居民基本医疗保险以及医疗救助制度达到全民覆盖的目的。在社会主义市场经济体制下首次将“全民”纳入到基本医疗保障制度之内,满足了被排除在医疗保障制度之外群体的诉求。但仅仅是在制度与政策上覆盖全体国民的医疗保险称不上真正意义上的全民医保,而且现有的医疗保险制度也存在诸多自身难以克服的问题。首先,目前的医疗保险制度存在明显的城乡二元特征,城镇职工、城镇居民、农村居民,身份特征明显,且制度之间差别较大,难以衔接与融合,不符合城乡社会经济一体化发展以及户籍制度改革等社会变革的要求；其次,不同人群享受不同的医疗保障待遇,进一步加大了城乡居民享受基本医疗卫生服务的差距,且出现了保障水平低与大量结余并存的不合理现象,不符合健康公平理论的要求；再次,不同的医疗保险制度由不同部门分管,机构、管理、人员、设备重复设置,既增加了管理成本,又给制度间的衔接造成了困难,不符合效率的原则。从医疗保险自身发展规律来看,我国目前也有必要从多元制度向一元制度发展,应以三大制度融合为切入点,努力缩小制度差别,取消制度边界,实现政策连接贯通,最终建立城乡一体的、覆盖全民的基本医疗保险制度,真正达到“全民医保”的目标。现有关于全民医保的研究大部分集中在制度发展方向、制度融合的可能性、制度应该具有的特征和应该遵循的原则等方面,并没有进行系统、完整地整理和总结,没有针对全民基本医疗保险提出一个明确的概念和界定。关于筹资的研究很多,但绝大多数是筹资方法、筹资模型、筹资标准及筹资指标的测算及确定,全民医保筹资的研究很少,且仅仅局限在定性分析上,至于全民基本医疗保险制度该如何进行筹资,筹资多少,筹资渠道有哪些,筹资能力如何等方面目前还没有系统的测算和分析。本研究的主要目的在于：明确在城乡一体化发展的背景下,全民基本医疗保险制度的概念内涵与性质特点；回答全民基本医疗保险制度下该如何进行筹资,以及相应的筹资标准、补偿标准、筹资额度、筹资主体如何确定等问题；分析各筹资主体的承担能力、筹资可行性以及政治、制度和社会情景,判断我国是否已经具备运行“全覆盖、低水平”全民基本医疗保险制度的条件；通过对目前已经实行一体化全民基本医保的地区进行实证研究,提取其值得借鉴和参考之处；理清目前在我国推行一体化全民基本医疗保险存在的实际问题以及相应的解决措施,并提出政策建议。研究方法研究采用定性研究与定量研究相结合的方法。定性研究方面主要通过文献复习法和专家咨询法,对一体化全民基本医疗保险的概念进行界定,并提出了相应的制度框架,为研究的进行打下了基础。筹资的测算采用了国家卫生部、财政部、国家统计局等权威机关公布的相关数据,按照“以支定收”的原则,利用了ILO模型中的成本估计子模型计算医药费用基数作为整个测算的基础,测算过程中涉及到的其它指标(保险因子、补偿比、风险基金、起付线与封顶线等),主要根据现有研究结果和专家咨询意见确定。收集到的数据采用Microsoft excel软件通过自编程序进行计算,每一步计算结果都与现有数据或相关文献进行了逻辑推理比较和验证,保证了数据的科学性与合理性。主要研究结果1、根据健康公平理论、底线公平理论、医疗保险理论、制度变迁与路径依赖理论以及相关文献和专家咨询结果,本研究对全民基本医疗保险制度进行了概括和总结。一体化全民基本医疗保险制度是我国政府为了保障城乡全体居民的基本健康权益,使其能够公平获得基本医疗服务所做出的制度安排；是为了给全体居民提供筹资保护与风险分担,改善卫生筹资公平性而做出的制度安排。从操作层面而言,全民基本医疗保险制度是一种服务于全民的、具有福利特征的制度,是一种统一但具有多种筹资标准的制度,全体居民不受身份和地域限制,根据自己的经济收入和承受能力选择合适的补偿方案,享受基本医疗服务时按照其选择的补偿方案得到相应补偿。即在制度架构上实现城乡统筹,在管理服务上实现城乡统一,在待遇标准上实现城乡基本一致,建立全国统一、系统整合、高效平等的制度框架,扩大保险覆盖面至整个人群,提高整个社会的风险共担和互助共济能力。2、以2008年全国医疗总费用作为测算依据,按照保险精算原理,测算了如果在当年度实行全民基本医疗保险所需要的筹资额度。考虑到各地居民经济能力不同,在一个制度框架中由高到低模拟了四种筹资和补偿方案,四种方案的补偿范围为住院补偿50%～80%,门诊补偿30%～60%,该范围包括了从“低水平、全覆盖”到“充分保障”的待遇水平。结果表明,在国家层面上进行统筹,四种补偿方案分别需要筹资3735.19亿元、5266.46亿元、7072.94亿元和9131.69亿元。主要通过政府和居民个人共同筹资,按照居民个人和政府分别承担30%和70%的比例,四种方案居民分别需要筹资1120.557亿元、1579.938亿元、2121.882亿元和2739.51亿元,分别占居民收入水平的0.813%、1.15%、1.54%和2%；政府分别需要筹资2614.6亿元、3686.5亿元、4951.1亿元和6392.2亿元,占2008年GDP的0.83%、1.17%、1.58%和2.04%。3、居民筹资可行性方面,随着居民收入水平的提高和存款额度的增多,如果居民有一定的筹资意愿,要拿出0.8%稍强的收入,参加“低水平、全覆盖”的保障水平应该不成问题。4、政府筹资可行性方面,近年来,我国经济稳步快速增长,给全民基本医疗保险打下了一个良好的经济基础。2008年我国税收收入较上年增加8413亿元,从数据上看,中央政府只要拿出国家税收收入增长量的20%～30%,就能够大大缓解全国居民的“看病难,看病贵”问题,达到“低水平、全覆盖”的目标。但要达到高标准的补偿方案,体现保险制度的福利特征,在国家投入方面短时间内可能会有一定难度。但我国目前的卫生总费用占GDP的比重尚未达到WHO要求的5%,更比不上发达国家的水平,也就是说我国政府在卫生投入方面还要进一步加强,如果在加大增量的同时能够对目前的存量进行科学调整,把握好资金的投入方向,就我国目前的经济实力而言,也不是不可预期的。5、我国政府有愿望,人民有需求,社会有呼声,政策有支持,从宏观角度而言,目前已经基本具备建立覆盖全民的基本医疗保险制度的社会、政治和经济条件。但在微观操作层面上,从制度建立、机构设置、筹资运作、管理协调、人才队伍等方面都还存在许多细节问题,就目前来说还不可能一蹴而就,需要分阶段、分步骤实施。6、通过对已经运行全民基本医疗保险的部分地区进行实证研究,得出要顺利运行全民医保制度需要达到以下几个要求：①缩小各项制度之间的差距,以便于实现城乡医保制度的衔接；②根据实际情况设置不同的保障标准或保障层次,逐步实现人群全覆盖；③构建统一、完善的管理机构；④拥有健全、高效、有能力的城乡卫生服务体系；⑤具备较强的政治优势和社会优势。结论和政策建议实行一体化全民基本医疗保险是我国医保制度改革的必然选择,也符合国际社会医疗保险的发展趋势。我国目前经济水平正快速稳步增长、民众对提高医保待遇的呼声日渐增强、社会保障体系日趋完善,已经具备开展全民基本医疗保险的宏观环境,但由于受到目前管理体制与机制的影响,还需要一定的过渡时期,在此期间内,应该充分了解变革的阻碍因素(或存在问题),注意各项制度在政策和机制上的逐步协调,以便在适当时机并轨运行。提出如下建议：(1)明确并落实政府职责,加大政府投入,调整政府支出结构,向基本医疗保障倾斜,同时加强各部门之间的协调机制建设；(2)逐步推进制度间的融合与机构间整合,同时加强与医疗救助制度的衔接,充分发挥医疗救助制度对贫困群体的救助作用；(3)加强制度宣传,保证居民受益程度,以提高居民的筹资意愿,同时要争取各利益相关集团的理解与支持；(4)提高统筹层次,最起码应该达到省(市)级筹资,充分体现地区间互助共济的意义；(5)加强立法进程,建立稳定高效的基金筹集机制；(6)注重因地制宜,短时间内各地区可以根据自身情况选择实行基本医疗保险的制度模式。更多还原

【Abstract】 BackgroundThe new medical reform program proposes to establish and improve the basic medical insurance system for all urban and rural residents by basic medical insurance of employees, new rural cooperative medical system(NRCMS) and basic medical insurance of residents. From the policy level, almost everyone can find their corresponding medical insurance system in the framework of current medical insurance systems. But it can not be called real universal health insurance if all people only be covered by system and policy. Moreover, the current medical insurance systems have some problems which can not be overcome by themselves.Firstly, the current medical insurance systems have obvious characteristics of urban and rural. There are major differences between the current systems, which are difficult to merge and integrate and do not meet the circumstance requirements of socio-economic integration development in urban and rural and the household register system refom. Secondly, different people enjoy different security benefits. It enlarges the medical service difference between the urban and rural residents and does not meet the requirement of health-equity theory. Thirdly, different medical insurance systems are in charged by different departments. It increases the cost of management and management difficulties, causes the convergence difficulty between several systems, does not meet the principle of efficiency and need for further reform and improvement. From the own development of medical insurance, we should transfer the current medical insurance systems from multiple systems to the single system, shorten the difference of three major systems, cancel the system border, realize the integration of different policies, or build a unified basic medical insurance system with universal coverage to achieve the target of "universal coverage".The existing studies about national basic medical insurance (NBMI) focus on the orientation of system development, the possibilities of system integration, the characteristics and principles should be followed. There is no summary and a clear concept and definition about NBMI. The current studies about financing were concentrated on financing methods, financing models, financing level, financing indexes etc. There are a few qualitative analyses about financing on NBMI recently but no quatitative study. The financing mechanism should be calculated and analyzed including how to finance, how many should be funded, what channel, how about the financing capacity etc.The main purpose of this study is to clarify the concept and features of NBMI, answer how to finance, how to determine the funding criteria, compensation criteria, funding limits and financing subjects, analyze the affordability of financing, financing feasibility and political, system, social situation, decide that if our country has the condition to run the NBMI, study those areas which have already implemented NBMI to obtain some references, clarify the problems that will be found in our implementation of NBMI and propose corresponding solutions and policy suggestions.Study methodsStudy uses qualitative and quantitative methods. We definite the conception of NBMI, propose corresponding institutional framework by qualitative research, primarily through literature review and expert consultation. We use the relative data from National Ministry of Health, Ministry of Finance, National Bureau of Statistics and other authoritative agencies to calculate the funding. According to the principle of "expenses determining revenue", we use the ILO model to estimate the medical expenses. The other indicators (insurance factor, compensation ratio, risk funds etc.) in the process are determined by literatures and expert advices. Microsoft excel software is used to arrange and calculate data. In every step of the calculation, we compare and testify the results with the existing datas or literatures to ensure that the results are scientific and rational.Main study results1. In this study, NBMIS is summarized and definited by the literature analysis, expert consultations and related theories, including health equity theory, underline equity theory, medical insurance theory, system transferrence theory, route depending theory etc. NBMIS is a system made by our government to ensure the basic health equity of all residents and ensure them to obtain basic medical services equally. NBMIS is a system to provide financing protection and risk sharing and improve health financing fairness. From the operation aspect, NBMIS services for all the people, possesses welfare feature, is a united system with multi-level. All people must attend NBMIS free form identity and geographical constraints. They can select appropriate compensate packages voluntarily according to their income and affordability. The residents access to basic health care services in accordance with the compensation packages they chose accordingly. In the same way, urban and rural use one institutional framework together, the management of services achieves reunification in urban and rural areas, the treatment standards achieve consistent in urban and rural areas. The goal is to expand the insurance coverage to all people and increase the risk-sharing capacity.2. According to the actuarial principle, study estimates the amount of funding needed to operate the NBMIS at the basis of 2008 national medical expenses. Taking into account the economic capacity of residents in different areas, study imitates four compensation packages in one system framework. The compensation range is:inpatient compensation 50% to 80%, outpatient compensation 30% to 60%.The results show that at the national level, the amount of funds required for the four compensation packages are 373.519 billion yuan, 526.646 billion yuan,707.294 billion yuan and 913.169 billion yuan respectively, which is afforded by residents and government together. If the residents take 30% and the government takes 70%, then the residents need fund 112.0557 billion yuan,157.9938 billion yuan,212.1882 billion yuan and 273.951 billion yuan, which is 0.813%,1.15%,1.54% and 2% account of income level respectively. The government needs fund 261.46 billion yuan,368.65 billion yuan,495.11 billion yuan and 639.22 billion yuan, which is 0.83%,1.17%,1.58% and 2.04% account of GDP in 2008 respectively.3. In recent years, the residents’revenue is improving, and the deposit is growing. In this situation, if. the residents have funding desire, coming up with 0.8% of revenue to participate in the medical insurance of "low-level, universal coverage" should not be a problem.4. In the recent years, the economy index is growing quickly and steadily in our country, which is a good economic foundation for NBMIS. China’s tax revenue increased 841.3 billion yuan over the previous year in 2008. From a data perspective, if the central government can come up with 20% to 30% of the state’s tax revenue growth, can we reach the target of "low level, universal coverage". There indeed is certain difficult if we want to achieve a high standard of compensation package and reflect the benefits characteristics of NBMIS. However, the total health expenditure in China accounted for the proportion of GDP has not yet reached WHO requirement of 5%, that is to say, our government should strengthen the health inputs further. If we can increase inputs, make the scientific stock adjustment at the same time and grasp the funding direction, NBMIS of a high standard is not unexpected from our current economic strength.5. From macroscopy respect, our country has possesses the basic condition to build NBMIS including social condition, policy condition, economy condition and system support. But from the microscopy respect, there are many problems, including system construction, organization installation, financing operation, management cooperation, human resources etc. So we can not reach NBMI in a short time, we need carry out the NBMIS step by step.6. Through the demonstration study in some regions, which have already implemented the NBMI, we analyze the condition that should be reached to operate the NBMI smoothly. Such as the following requirements:①shortening the gap between the various systems to achieve the convergence of medical insurance systems in urban and rural;②setting different compensate levels according to the actual situation to achieve universal coverage;③building a unified and perfect management institution;④having a sound, efficient and capable health service system in both urban and rural;⑤having strong political and social advantages.Conclusion and policy suggestionsNBMI is an inevitable choice in the reform of medical insurance system, also in line with the development trends of health insurance in global societies. China’s economic level is growing rapidly and steadily, the people are calling for improving the treatment of health insurance, the social security system’is being completed, these advantages indicate that we have already had the circumstance to carry out the NBMI. Because of recent manage mechanisms and systems, we need certain transition period. During this period, we should understand the impediments of transferrence (or the problems) fully, note the coordination of policies and mechanisms, so as to merge at an appropriate time.According the results, we make the following advices:(1) increase government investment, adjust the structure of government spending and give greater priority to basic medical care, strengthen the coordination mechanisms between various departments at the same time; (2) advance the inter-system integration and inter-agency integration gradually, strengthen the link with the medical aids system so as to decrease the poverty due to sickness. (3) strengthen institutional publicity, ensure the benefits degree, improve the willingness of financing, and seek understanding and support from the stakeholder groups; (4) improve the financing level to provincial(municipal) level at least, fully reflect the significance of regional aims at treating; (5) strengthen the legislative process, establish a stable and efficient fund-raising mechanism; (6) develop different medical insurance systems based on different special situations of regions and groups in a short time, select different models according to the difference of socio-economic conditions (eastern, middle and western of china) and their demands at present.更多还原