新型农村合作医疗基金统筹研究
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摘要
城乡医疗保险的一体化是我国医疗保障事业发展的必然趋势,但医疗保险基金供给的制约成为城乡医疗保险一体化的主要障碍。本文以新型农村合作医疗基金为主要研究对象,笔者运用规范分析、实证分析、比较分析、定量分析和定性分析等方法分析了新农合基金的供给与需求现状,并以此为基础探讨了在资金供给制约下城乡医疗保险一体化“基金统筹先行”的现实路径,然后分析了新农合基金统筹的必要性、可能层次和可行路径。
按照现行的新农合筹资模式,根据当前的参合比率和财政支出结构,新农合基金在未来10年的时间内呈现出稳定的增长趋势,若按照现行的新农合补偿政策,新农合基金在未来的2009—2020年间将呈现供大于求的趋势。但新农合和城镇居民医疗保险当前的补偿政策都存在着政府划定的补偿政策范围过小及报销比例偏低等问题。要实现城乡医疗保险体系的相对一体化,即让城镇职工医疗保险、城镇居民医疗保险和新型农村合作医疗有着相同的政策补偿范围和报销比例,基金供给是最大的制约因素,因此在基金供给不可能在短时间内满足需求的情况下,城乡医疗保险的一体化必须走“统筹先行”的发展路径。对于基金筹集而言,必须提高新型农村合作医疗基金和城镇居民医疗保险的财政补偿力度及参保人员缴费标准,对于新农合基金的筹集而言,中央财政必须承担更大的支出责任,东中西部的地方政府也应当根据当地经济发展的实际状况承担相应责任。
当前,新农合基金的县级统筹造成了监管困难、基金的抗风险能力减弱、基金的调剂空间受限、基金的效能难以充分发挥、保险的公平性受到损伤等一系列问题,这也成为城乡医疗保险一体化的重要制约因素,而提高新农合基金的统筹层次能够有效地克服上述弊端,提高参保群体的受益水平。新颁布的《社会保险法》已将提高各类社会保险基金的统筹层次写入其中,因此,提高新农合基金的统筹层次便势在必行。新农合基金统筹包括县级统筹、市级统筹、省级统筹和国家统筹等可能层次,省级统筹是新农合基金必要的最终统筹层次。选择跨市统筹的路径即在条件成熟的情况下将医疗保险基金的统筹层次从县级直接提高到省级不仅能够克服低层次统筹的各种问题,还能够节省统筹的成本,但当前条件下可以允许经济较为发达的地方尝试逐级统筹的路径。文章对于新农合基金未来供给与需求趋势的预测以及基于资金约束条件下的城乡医疗保险一体化的路径设计具有前瞻性,对于新农合未来筹资政策的调整方向、新农合基金统筹最高层次的界定及统筹可行路径的分析具有创新意义。
Integration of both urban and rural medical insurance is an inevitable trend of development of Chinese medical security cause, but restriction on supply of medical insurance funds has become its major obstacle. Taking the NCMS funds as the main research object, the paper analyses the status quo of supply and demand of NCMS funds by combination of normative, positive, and comparative methods, based on it discusses practical path of“co-ordination in advance”for integration of both urban and rural medical insurance under financial restriction and finally investigates necessity, potential level and feasible path of co-odination of NCMS Funds.
The new type of rural cooperative medical service has been launched for more than eight years in China. Its participant has exceeded 95 percent of those who are involved in the agricultural section and also the scale of fund has gradually enlarged. However, the county-level arrangement of the NCMS funds have led to a series of problem such as regulatory difficulty, decrease of anti-risk capability of the fund, restriction on adjusting room for fund, deficient exertion of the fund’s function, impairment of insurance fairness. Therefore, heightening the arrangement level of NCMS funds can in effect overcome malpractices mentioned above and improve the insurance participant benefit. The Social Insurance Law that is newly promulgated has included enhancing arrangement level of kinds of social insurance fund and consequently issues on enhancing the arrangement level of NCMS funds will receive concern from both researchers and policy-makers.
The paper mainly focuses on NCMS Funds, analyses its necessity, potential level and feasible path by combination of normative, positive, and comparative meathods. Meanwhile it predicts not only the demand status of NCMS Funds based on the province-level arrangement but supply status of NRCF according to the current financing model of the new type of rural cooperative medical service (NCMS), measures the gap between them and designs corresponding adjustive scheme of financing policy. Finally, in light of funds constraint of China’s different type of mecial insurance, the paper discusses realistic path of integrating both urban and rural medical insurance.
Based on the current financing model of NCMS as well as its participating ratio and fiscal expenditure, the NCMS funds will manifest a steady increasing trend within 10 years. Supposedly according to the current compensation policy, the NCMS funds will see a trend of oversupply from 2009 to 2020. Nevertheless, the current compensation policy of the urban resident’s medical insurance of NCMS funds has such problems as less scope and lower writing-off ratio drawn by the government. In order to realize relative integration of both urban and rural medical insurance system that enables the urban employee’s medical insurance, the urban resident’s medical insurance and NCMS funds to enjoy the same compensation scope and writing off ratio, we should intensify the degree of the fiscal compensation and raise the payment standards of the participant and as to finance of NCMS funds, Central finance must play an bigger role in expenditure. In light of the current both urban and rural resident income level, within10 years there exists great difficulty in achieving absolute integration of medical insurance that leads both the urban employeement and the urban resident medical insurance along with the participant of NCMS to experience completely equal medical service treatment. Therefore, for the sake of ultimately implementing integration of both urban and rural medical insurance, a developmental path of“overall-arrangement in advance and integration later on”would be feasible and practical. Co-odination of NCMS funds spans county-level, city-level, province-level and national-level and provincial arrangement is its indispensable ultimate level. Choice of cross-city arrangement path means under the mature condition directly improving the arrangement level of the medical insurance fund from county-level to the provincial level. It can not only overcome kinds of problems of the lower level arrangement, but also save cost. However, presently, areas of comparatively advanced economy may be allowed to attempt the path of level by level arrangement.
按照现行的新农合筹资模式,根据当前的参合比率和财政支出结构,新农合基金在未来10年的时间内呈现出稳定的增长趋势,若按照现行的新农合补偿政策,新农合基金在未来的2009—2020年间将呈现供大于求的趋势。但新农合和城镇居民医疗保险当前的补偿政策都存在着政府划定的补偿政策范围过小及报销比例偏低等问题。要实现城乡医疗保险体系的相对一体化,即让城镇职工医疗保险、城镇居民医疗保险和新型农村合作医疗有着相同的政策补偿范围和报销比例,基金供给是最大的制约因素,因此在基金供给不可能在短时间内满足需求的情况下,城乡医疗保险的一体化必须走“统筹先行”的发展路径。对于基金筹集而言,必须提高新型农村合作医疗基金和城镇居民医疗保险的财政补偿力度及参保人员缴费标准,对于新农合基金的筹集而言,中央财政必须承担更大的支出责任,东中西部的地方政府也应当根据当地经济发展的实际状况承担相应责任。
当前,新农合基金的县级统筹造成了监管困难、基金的抗风险能力减弱、基金的调剂空间受限、基金的效能难以充分发挥、保险的公平性受到损伤等一系列问题,这也成为城乡医疗保险一体化的重要制约因素,而提高新农合基金的统筹层次能够有效地克服上述弊端,提高参保群体的受益水平。新颁布的《社会保险法》已将提高各类社会保险基金的统筹层次写入其中,因此,提高新农合基金的统筹层次便势在必行。新农合基金统筹包括县级统筹、市级统筹、省级统筹和国家统筹等可能层次,省级统筹是新农合基金必要的最终统筹层次。选择跨市统筹的路径即在条件成熟的情况下将医疗保险基金的统筹层次从县级直接提高到省级不仅能够克服低层次统筹的各种问题,还能够节省统筹的成本,但当前条件下可以允许经济较为发达的地方尝试逐级统筹的路径。文章对于新农合基金未来供给与需求趋势的预测以及基于资金约束条件下的城乡医疗保险一体化的路径设计具有前瞻性,对于新农合未来筹资政策的调整方向、新农合基金统筹最高层次的界定及统筹可行路径的分析具有创新意义。
Integration of both urban and rural medical insurance is an inevitable trend of development of Chinese medical security cause, but restriction on supply of medical insurance funds has become its major obstacle. Taking the NCMS funds as the main research object, the paper analyses the status quo of supply and demand of NCMS funds by combination of normative, positive, and comparative methods, based on it discusses practical path of“co-ordination in advance”for integration of both urban and rural medical insurance under financial restriction and finally investigates necessity, potential level and feasible path of co-odination of NCMS Funds.
The new type of rural cooperative medical service has been launched for more than eight years in China. Its participant has exceeded 95 percent of those who are involved in the agricultural section and also the scale of fund has gradually enlarged. However, the county-level arrangement of the NCMS funds have led to a series of problem such as regulatory difficulty, decrease of anti-risk capability of the fund, restriction on adjusting room for fund, deficient exertion of the fund’s function, impairment of insurance fairness. Therefore, heightening the arrangement level of NCMS funds can in effect overcome malpractices mentioned above and improve the insurance participant benefit. The Social Insurance Law that is newly promulgated has included enhancing arrangement level of kinds of social insurance fund and consequently issues on enhancing the arrangement level of NCMS funds will receive concern from both researchers and policy-makers.
The paper mainly focuses on NCMS Funds, analyses its necessity, potential level and feasible path by combination of normative, positive, and comparative meathods. Meanwhile it predicts not only the demand status of NCMS Funds based on the province-level arrangement but supply status of NRCF according to the current financing model of the new type of rural cooperative medical service (NCMS), measures the gap between them and designs corresponding adjustive scheme of financing policy. Finally, in light of funds constraint of China’s different type of mecial insurance, the paper discusses realistic path of integrating both urban and rural medical insurance.
Based on the current financing model of NCMS as well as its participating ratio and fiscal expenditure, the NCMS funds will manifest a steady increasing trend within 10 years. Supposedly according to the current compensation policy, the NCMS funds will see a trend of oversupply from 2009 to 2020. Nevertheless, the current compensation policy of the urban resident’s medical insurance of NCMS funds has such problems as less scope and lower writing-off ratio drawn by the government. In order to realize relative integration of both urban and rural medical insurance system that enables the urban employee’s medical insurance, the urban resident’s medical insurance and NCMS funds to enjoy the same compensation scope and writing off ratio, we should intensify the degree of the fiscal compensation and raise the payment standards of the participant and as to finance of NCMS funds, Central finance must play an bigger role in expenditure. In light of the current both urban and rural resident income level, within10 years there exists great difficulty in achieving absolute integration of medical insurance that leads both the urban employeement and the urban resident medical insurance along with the participant of NCMS to experience completely equal medical service treatment. Therefore, for the sake of ultimately implementing integration of both urban and rural medical insurance, a developmental path of“overall-arrangement in advance and integration later on”would be feasible and practical. Co-odination of NCMS funds spans county-level, city-level, province-level and national-level and provincial arrangement is its indispensable ultimate level. Choice of cross-city arrangement path means under the mature condition directly improving the arrangement level of the medical insurance fund from county-level to the provincial level. It can not only overcome kinds of problems of the lower level arrangement, but also save cost. However, presently, areas of comparatively advanced economy may be allowed to attempt the path of level by level arrangement.
引文
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姚洋,杨雷.2003.制度供给失衡与中国财政分权的后果.战略与管理,(3):33-38
叶明华.2011.堵上新农合欺诈的“黑洞”.中国社会保障,(2):47-50
由建勋. 2006.化解新型农村合作医疗基金风险的对策研究.农业经济,(3):42-45
张洪林. 2006.浅谈新型农村合作医疗基金收支的监督.江苏卫生事业管理,(2):30-33
张家成. 2001.管好人和事管住养老钱—陕西省养老保险经办机构实行垂直管理.中国劳动,(4):17
张利军. 2009.中国养老保险统筹层次的改革路径与发展方向探讨.中国劳动关系学院学报,(8):25-28
张思锋. 2006.社会保障精算理论与应用.北京:人民出版社:157-162
张雪. 2006.刍议新型农村合作医疗基金的会计管理.财政监督,(3):20-21
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郑功成.2009.医保制度多元分割运行:不公平、损效率.中国劳动保障报,06-09
郑永年.2004.中国需要建设国家认同.环球时报,08-16
钟志文.2009.福建实践基本养老保险省级统筹的启示.中国社会保障,(3):51-53
周爱萍. 2009.对建立城乡一体化基本医疗保险制度的思考.经济研究导刊,(13):82—83
朱锋.2005.爱国:中国人的骄傲与忧思.中国与世界观察,(1):36-39
左高山.2010.政治忠诚与国家认同.马克思主义与现实,(2):57
左学金,王耀忠. 2003.建立和完善农村医疗保障制度的几点思考.社会科学,(12):25-29
Barro J.& Beaulieu N.2003.“Selection and Improvement:Physician Responses to Financial Incentives”, NBER working paper 10017
Bennett S. 2004.“The Role of Community-based Health Insurance with in the Health Care Financing System:a Framework for Analysis”,Health Policy andPlanning,19(3),147-158,Oxford University Press
Bennett S.,A.Creese,and R. Monasch. 1998. Health Insurance Schemes for People Outside Formal Sector Employment,ARA Paper No.16,WHO,Geneva,
Bloom G.&Tang Shenglan. 1999.“Rural Health Prepayment Schemes in China: towards a More Active Role for Government”,Social Sciences&Medicine,48,
Bohmer R. 2003.“Note on Managed Care”. Inside Health Care,Harvard Business School Publishing,
Buchanan, Allen. 1998. Managed Care: Rationing without Justice,but not Unjustly.Journal of Health Politics,Policy and Law, 23(4):617-634.
Getzen,T.E. 2000. Health Care is an Individual Necessity and A National Luxury: Applying Multilevel Decision Model to the Analysis of Health Care Expenditures.Journal of Health Economics, 19(2):259-270.
Guy Carrin. 2003.Community based health insurance sehemes in developing countries: faets, Problem sand Pers Pectives,WHO
James, Estelle. 2000. Social Security around the World in Soeial Seeorrt一what role for the future .Woshington D.C.: National Academy of Soeial.Insurance,15
Johanna Jacob, Douglas Lundin. 2005. Amedian Voter Model of lnsurance with expost moral hazard. Journal of Health Eeonomics,(2)
Levit, Katharine,Cathy Cowan, Helen Lazenby, Arthur Sensenig,PatriciaMcDonnell, Jean Stiller, Anne Martin,and the Health Accounts Team:“HeathSpending in 1998: Signals of Change”,Health Affairs19.January/February ,2000(1):124-132.
Martin S.Feldstein, 1973.“The Welfare Loss of Excess Health Insurance”Journal of Political Economy, (March).
Pip Klein. 2003.Medicare reform draws praise and criticism.Fairfield County Business Journal, Dec15 W.Henry Chiu, 1997.“Health insurance and the welfare of health care consumers”.Journal of Public Economics(64)
W1lensk,Lebeau. 2000. Industrial soeiety and social welfare.The Free press,21