贫困人口医疗救助的经济学分析

【作者】 褚亮；

【导师】 梁鸿；

【作者基本信息】 复旦大学 ， 人口、资源与环境经济学， 2009， 博士

【摘要】 随着中国改革开放与社会经济的快速发展，以及社会快速转型和贫富差距不断扩大，城市地区不可避免地出现了“新贫困群体”。虽然中国政府已经通过城镇低保制度基本解决了城市贫困人口的生计问题，但是短期内他们的收入水平难以提高，这就使其仍无法承受基本生存以外的其它风险，其中，与生命息息相关的疾病风险造成的危害最大。在社会的广泛呼吁下，一项政府主导的保障社会底层人群基本医疗需求的城市医疗救助制度已于2005年初正式建立起来。作为一项医疗保障前沿制度，贫困医疗救助日益受到卫生经济领域和社会保障领域专家学者的关注，尽管他们已做过大量研究，但都仅限于评价制度效率或效果，以及估算应有的资金支出规模，对于这项制度今后应朝着什么方向发展普遍认识不深刻，因此他们的研究常常止步于制度评估、资金测算，而对于制度完善的根本瓶颈——公共财政投入不足，尚无有效的解决方案。另外，鼓励与支持建立医疗救助制度的理论较为丰富，然而可以转化为实证研究的不多，因为缺少可操作性。鉴于学术界目前存在上述研究真空和研究不足，本文借助一些贫困项目和卫生服务项目的调查数据，对上述经典理论(例如卫生服务公平理论)进行了实证研究，并对“免费基本医疗”这种医疗救助的创新模式进行了论证，说明它可以实现对有限救助资源的高效运用，并且符合医疗救助制度的服务之本——保障贫困人口的基本医疗需求。除文献综述外，本文重点章节分为以下五个部分：第三章对疾病如何降低家庭生活水平的逻辑过程进行了梳理，用数据分析证明疾病不仅可以造成一个家庭的收入性贫困，还会造成一种支出性贫困，而最终的负面效应(陷入绝对贫困)是两种效应的综合。上述研究其实是对“因病致贫”这一抽象理论的具体化，夯实了其实证基础。同时，对传统的低保资格审核制度提出质疑，认为只依据收入变量无法准确度量一个家庭的贫困程度。第四章针对卫生服务公平理论体系中的“利用公平”展开实证研究，借助上海市居民卫生服务调查的数据说明，一个人实际利用的卫生服务数量可以分解为卫生需要预期得到的数量和用货币购买的数量，贫困人口在卫生需要与一般人口相同的前提下(通过计量方法实现)对卫生服务的利用不及后者，可见贫困人口存在严重的看病就医难题。有了卫生服务利用不公平的结果，本文再进一步描述贫困人口曲折的医疗消费过程，方法是考察低保人口与非低保人口在就诊概率、住院级别、治理结果等方面的差异。第四章实际是强调贫困人口存在旺盛的医疗救助需求，在此基础上，第五章对现阶段的制度供给进行了评述。首先回溯制度产生及发展的过程，发现制度经过革新后仍存在资金供需矛盾。由于医疗救助只承担基本医疗服务产生的费用(制度本质)，故它对贫困人口的医疗支出(未经医保报销部分)无法实现100%补偿。对城乡医疗救助制度进行横向对比，发现后者通过实现与新农合制度的无缝衔接，为贫困人口的大病支出开拓出新的公共卫生资源。然而，目前这种救助、医保互相补充的模式还不适合城市，因此城市地区应创新一种免费门诊的救助模式，这是该项制度未来的发展趋势。第六章先阐释基本医疗服务的内涵，再说明以社区医院作为免费门诊救助模式的服务载体，是基于社区医院能够提供价廉质优的基本服务。通过收集免费医疗项目的调查数据，分析说明这种制度模式能够有效促进贫困人口利用卫生服务，减轻其医疗负担，今后可以在更广泛的人群范围内进行制度拓展。第七章重述了第三章的结论——低保制度的资格甄别机制存在漏洞，目的是说明这种漏洞将影响医疗救助新模式的运行效率，出现“搭便车”的道德风险。最后强调医疗救助制度对救助对象的筛选，既应该有和低保制度重合的方面(即首先要符合收入性贫困)，又应该具有自身的特点(即还要考察疾病引起的支出性贫困)。医疗救助在资金有限的前提下可以先对健康脆弱成员比较多的贫困家庭实现覆盖。健康脆弱成员是指14岁及以下儿童和60岁及以上老人。更多还原

【Abstract】 The new poverty colony has emerged since China’s embarking on the path of reform andopening-up,the rapid development of social economy,the rapid social transformation and theexpanding of the income disparity.Although China’s government has almost solved the livingproblem of poor people by implementing basic living system,their income could hardly beimproved in a short time;therefore,they still can not bear any kind of risks except living.Amongall of the risks,diseases could bring the most harmful results to poor people.Under thecircumstances of social appeal,a government-leading Medical-Aid system which is aimed atguaranteeing poor people’s basic medical demand was built up in 2005.Because it is a newly-emerged medical insurance system,there has been an increasing interestin Medical-Aid researching.Although many researchers have conducted lots of analyses,most ofthem are limited on evaluating its effectiveness or estimating the expected demand for aidingfunds.So far,no one has a clear idea about what is the next stage of MA system.The aboveanalyses were only aimed at fixing the disadvantage of MA and contributed a little about how tocope with the shortage of public funds.There have been many theories supporting the implementof MA system,but few of them can be proved by empirical research.Because of the shortage ofvaluable researches on MA,the author plans to make use of some survey on poverty and medicalservices to prove the existing theory,and point out a new pattern of MA system which is free andguarantees the basic medical demand has a advantage of using limited funds with high efficiency.Besides the summarization of existing articles,the main content of this dissertation is separatedin 5 parts.Chapter 3 will conduct an empirical research on how diseases lead to poverty.In fact,a familywith sick members will fall into absolute poverty easily,because of both low income and largequantity of medical expense.This dissertation will build an empirical foundation for the alreadyexisting conclusion.In addition,this dissertation will put the effectiveness of basic living systemin doubt,because a family’s degree of poverty can not be measured just by its income.Chapter 4 will analyze what’s the inequity of medical consumption between rich and poorpeople by using some data captured from medical survey.The amount of enjoyed services isdetermined by a person’s medical need and his economic power.The author will prove those poorpeople with the same medical needs as the rich actually consumed less medical services than thelatter.So we can say poor people had difficulty in making using of medical resources.In addition,the author will conduct a statistic description of the realistic obstacle for poor people inconsumption.The 4th chapter already proves poor people’s demand for Medical-Aid system is very huge.As a contrast to the demand,Chapter 5 will evaluate the efficiency of system supply.Firstly,theauthor will have a retrospect of the building-up and developing procedure of MA system,and thenpoint out the its recent pattern can still not solve the conflict between fund supply and demand.MA system is aimed at satisfying poor people’s basic demand for curing diseases,so it should notbe used to compensate poor patients’ whole medical fees.The author found out the MA system incountryside is more successful than that in urban area,because it linked itself efficiently tomedical cooperation system and alleviated the poor farmers’ burden by making use of newmedical resources.It is a pity that this model is not suitable for urban MA system,so governmentshould develop a new pattern named free and basic health care.Chapter 6 will explain what basic medical service is and why this kind of services should besupplied by community hospital.The author will conduct a comparison between 2 groups ofpeople which are separated by MA system.The conclusion is,the new form of MA system issuccessful in encouraging poor people to cure their diseases without regard to their income,andalleviating their medical costs.This new pattern of MA system is welcomed by poor citizens andwill be developed though investing more public finance,so that it can serve more people inpoverty.Chapter 7 will re-mention the above conclusion (Chapter 3) that the basic living system can notdistinguish real poor people from the fake ones,in order to point out this advantage would affectMA system’ efficiency.There must be the problem of“free riding”on this condition.In order todetermine which family should be bared exactly,MA system should not only refer to the standardof basic living system,but also rely on its own.That is to say,it can distinguish a real poor familyaccording to whether it has children or old members.Since diseases can lead a family into povertyin a high possibility,MA system’s distinguishing mechanism can reduce the bias from poverty,which is caused by basic living system and will absolutely exist.更多还原