基本医疗保险一体化制度研究

发布时间：2018-06-29 19:54

本文选题：基本医疗保险一体化 + 筹资模式　；参考：《南开大学》2014年博士论文

【摘要】：本文是一个关于基本医疗保险一体化制度的探索性研究,通过相关的理论研究、政策分析与经验研究,将社会政策分析与规范经济学研究运用到基本医疗保险制度领域的研究。论文将卡尔·波兰尼的“嵌入性”理论作为基本医疗保险一体化制度的分析框架之一,梳理了基本医疗保险一体化制度可能的理论基础,结合经济学的分析视角,论证了基本医疗保险一体化制度的核心要素及其制度框架,在此基础上,论文围绕着作为基本医疗保险制度体系的三个主体即医疗保险机构、被保险人、医疗服务提供者之间的本质关系及其内在矛盾,借助二手文献资料的分析与相关数据,阐释了我国现行基本医疗保险制度在改革过程中面临的问题及其深层次的影响因素,并借鉴英国、美国及加拿大三国医疗保险一体化的制度框架与路径,主要从筹资模式、医疗费用支付方式及医疗保险经办机构三个方面提出建构基本医疗保险一体化制度的政策建议。通过相关的理论分析与经验考察,本文的研究发现如下：第一,我国已经建立以城镇职工基本医疗保险制度、城镇居民基本医疗保险制度和新型农村合作医疗制度为主体的基本医疗保险制度体系,现行基本医疗保险制度体系的三大主体制度分属不同的部门管理,各自独立封闭运行,并且三者的筹资水平、保障水平差异较大,筹资公平性较差,呈明显“碎片化”特征。第二,在社会政策学层面,论证了卡尔·波兰尼的“嵌入性”理论作为基本医疗保险一体化制度的社会政策学分析框架之一,提出现代社会存在着“市场-社会”之间的吊诡关系：虚拟商品与社会自我保护运动之间的内在矛盾。以公民身份作为个人享受社会权利的标准可使劳动力去商品化并作为一种社会政策的理论指向,这种理论指向是突破“市场-社会”吊诡关系的路径和选择,并成为社会政策研究的逻辑起点。基本医疗保险一体化制度的理论基础正是基于在“市场”必然嵌入“社会”的前提下,以社会公民的权利为资格使得每个公民在处于任何社会条件下都能公平地获得基本医疗保险。第三,基本医疗保险制度的经济学分析显示,由于医疗市场的不完性以及个人的有限理性使得健康消费会产生外部性,当消费者的收入一定时,无论消费者是否对健康进行消费或投资,都会产生福利上的净损失。因此,消费者所产生的福利净损失就只能由政府提供的基本医疗保险制度来化解和弥补。同时,健康税的分配效应表明,对高收入者征税与对低收入者进行收入再分配是对市场扭曲程度最小的办法。高收入者的福利减少被低收入者福利增加抵消了一部分,从而使整体福利的净损失不至于太大。第四,对英国、美国、加拿大三国医疗保险制度的比较分析表明,作为商业医疗保险型的美国与全民医疗服务模式的英国及加拿大在医疗保险制度的建构、内容的设计以及与之相关的价值观存在着较大差异,但就三个国家的筹资模式而言,美国公立医疗保险体系的筹资模式与英国、加拿大两国的筹资模式是高度相似的,即以一般税作为筹资渠道及来源。因此,在这个意义上说,通过一般税收的筹资模式是构建基本医疗保险一体化的最佳筹资路径。第五,基于以上分析,基本医疗保险一体化制度的建构基于以下几点：第作为医疗市场的第三方支付者,以成功的价格谈判机制和合理的费用支付方式有效地平衡医、患、保三者之间的关系；第二,作为健康风险的集中者,使所有消费者都具有获得健康的平等权利；第三,作为医疗市场不完全性的弥补者,有效弥补个人健康消费的有限理性,并具有对低收入者和高收入者的再分配效应。由于健康风险与老年风险存在较大的差异,使得医疗保险的制度安排不能简单模仿和照搬养老保险制度。因此,基本医疗保险的筹资机制应该与养老保险独立开来,对工薪进行课税作为筹资方式,采用以总额预付制为主的费用支付方式并设立统一的医疗保险经办机构负责资金配置以及向医疗服务机构付费和价格谈判,从而实现基本医疗保险一体化的制度建构。
[Abstract]:This article is an exploratory study of the integration of basic medical insurance. Through the relevant theoretical research, policy analysis and empirical research, the research of social policy analysis and normative economics is applied to the basic medical insurance system. The thesis uses Karl Polanyi's "embeddedness" theory as the basic medical insurance. One of the analytical frameworks of the integration system, combing the possible theoretical basis of the basic medical insurance integration system, and combining with the perspective of economic analysis, demonstrated the core elements and the institutional framework of the basic medical insurance integration system. On this basis, the paper revolves around the three main bodies of the basic medical insurance system, namely medical treatment. The essential relations and internal contradictions between the insurance institutions, the insured and the medical service providers, with the help of the analysis and relevant data of the second-hand literature, explain the problems faced by the current basic medical insurance system in China and the deep influence factors in the process of reform, and draw on the medical insurance of the three countries in the United Kingdom, the United States and Canada. The integrated system framework and path, mainly from three aspects of financing mode, medical expense payment method and medical insurance agency, put forward the policy suggestions for the construction of the basic medical insurance integration system.
First, China has established the basic medical insurance system based on the basic medical insurance system for urban workers, the basic medical insurance system of urban residents and the new rural cooperative medical system. The three main body systems of the current basic medical insurance system belong to different department management, respectively, independent and closed operation, and three parties. The level of financing, the level of protection is quite different, and the fairness of financing is poor, showing a "fragmentation" feature.
Second, at the social policy level, it demonstrates Karl Polanyi's "embeddedness" theory as one of the social policy analysis frameworks of the basic medical insurance integration system, and puts forward the paradox between the "market society" in modern society: the internal contradiction between the virtual goods and the social self-protection movement. As the standard of personal enjoyment of social rights, identity can make the labour force commercialized and point to the theory of a social policy. This theory points to a path and choice to break through the paradox of "market society", and is the logical starting point for the research of social policy. The theoretical basis of the basic medical insurance system is based on the theory of the theory The "market" must be embedded in the "society", with the rights of social citizens as a qualification for every citizen to be able to obtain a fair basic medical insurance under any social condition.
Third, the economic analysis of the basic medical insurance system shows that, because of the lack of medical market and the limited rationality of the individual, the healthy consumption will produce externality. When the consumer's income is certain, the net loss of welfare is caused by whether the consumer is consuming or investing in health. At the same time, the distribution effect of health tax shows that the tax on high income persons and the redistribution of income to the low-income people are the least distortions to the market. The welfare reduction of the high income is partly offset by the increase in the welfare of the low income. The net loss of the overall welfare will not be too large.
Fourth, a comparative analysis of the medical insurance system in Britain, the United States and Canada shows that there are great differences in the construction of the medical insurance system, the design of the medical insurance system, the design of the content and the values associated with the British and Canadian model of the commercial medical insurance and the national medical service model of the United States and the whole nation, but on the financing mode of the three countries, In the United States, the financing model of the American public health insurance system is highly similar to that in Britain and Canada. That is, the general tax is used as a fund-raising channel and source. Therefore, in this sense, the financing mode of general tax is the best way to build the basic medical insurance.
Fifth, based on the above analysis, the construction of the basic medical insurance integration system is based on the following points:
As a third party payer in the medical market, the relationship between doctors, patients and the three parties is effectively balanced by a successful price negotiation mechanism and a reasonable cost payment method; second, as a concentration of health risks, all consumers have the equal right to gain health; third, as a remedy for the incompleteness of the medical market, there are It makes up for the limited rationality of personal health consumption, and has the redistribution effect on the low income and the high income people. Because of the great difference between the health risk and the elderly risk, the institutional arrangement of medical insurance can not simply imitate and copy the pension insurance system. Therefore, the financing mechanism of the basic medical insurance should be independent of the pension insurance. As a fund-raising method, the salary payment method based on total prepayment system and the establishment of a unified medical insurance agency responsible for the allocation of funds and the payment and price negotiation to the medical service institutions are set up to realize the system construction of the integration of basic medical insurance.
【学位授予单位】：南开大学
【学位级别】：博士
【学位授予年份】：2014
【分类号】：F842.684;R197.1

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