农村健康保障制度中的主体行为研究
摘要
本文主要研究农村健康保障制度中各主体行为模式的形成机制,以解释当前农村健康保障制度发展中面临的问题和困境,并进一步探讨在现存的约束条件情况下,应如何创新激励机制,以矫正各主体行为的偏差。同时反思农村健康保障制度的建构理念,提出全民健康保障制度的理论设想,并对政府的责任作了初步的测算。健康融资的方式对实现健康制度的目标有重要的影响。健康融资的组织方式涉及风险集合和资源集合,对不同收入群体使用健康服务产生影响。保险计划的引入同时对于需求和供给的其他变量产生影响。社区健康融资安排的发展与小额融资、社会资本、主流理论的发展密切相关。
经济体制改革以来农村卫生工作令人担忧,其主要原因在于健康保障机制缺失下的高额治疗费用障碍,疾病的经济风险增大。而疾病风险使农民陷入脆弱性,因此建立农村健康保障制度势在必行。
可以运用新制度经济学有关制度变迁的理论来分析合作医疗制度的变迁。合作医疗的早期繁荣是制度均衡的结果,合作医疗解体是在其内在矛盾的演化和外部环境的变化共同作用下,从均衡走向非均衡的结果。由于需求和供给的相互作用以及政府没有能够提供足够的支持,农村健康保障制度诱致性制度变迁和强制性制度变迁动力都不足,从而造成试图恢复合作医疗的努力并没有取得实质性的效果。新型农村合作医疗是政府在新的历史条件下主导的强制性制度变迁。
可以用资源动员、财务保障和社会包容的三维分析框架来评价社区健康融资(合作医疗)的绩效。农村合作医疗在风险分担和财务保障方面发挥了一定的作用,但在“低费用、高共付率”模式下,合作医疗受益存在着不公平性。
农民或农户是农村健康保障制度的需求主体,其需求状况,即其支付能力和支付意愿是合作医疗可持续发展的基础。通过扩展线性支出系统来测算农民或农户对合作医疗的支付能力,结果表明农村贫困人群存在支付能力的问题,但大多数中等收入以上的农民的主要问题是支付意愿。在国家层面上,影响支付意愿的因素主要是对政府的信任程度、政府的“机构能力”以及补贴的力度大小。社区层面的影响因素是社会资本。家庭对合作医疗的支付意愿主要取决于其对参保的成本和收益的比较,家庭风险分担机制和家庭之间风险分担机制也会对家庭的支付意愿产生影响。支付意愿还和农民的个人特征相关。
合作医疗实行强制并没有足够的合法性。强制投保可能防范了居民的“逆向选择”,但是却带来了管理人员和卫生服务提供者的“道德风险”。以家庭作为投保单位并不能绝对地增加参保人数,抑制逆选择,需要根据目标人群的具体特征
In the new Cooperative Medical System, the interactive among different related-interest groups or roles, such as providers, insured, fund and government agencies, jointly determines the efficiency of the system. The purpose of this dissertation is to analyze and discuss the behavior mechanism of related roles, demonstrate the challenges and dilemma, and further to discuss solutions to important incentive problems in which threaten their sustainability.Health financing has made important influence on the three goals of health systems: financial fairness, disability-adjusted life expectancy and responsiveness. Health financing involves risk pooling and resources pooling, which affects the use of health care for different income groups. The introduction of health insurance influences demand and supply and other variables. The growth of community-based health financing arrangements rests on developments in three related areas ,that is microfinance (microcredits, microsavings, microinsurance, financial intermediation), social capital (community, network, institutional, and societal links), mainstream theories (welfare of society, public finance, social policy, and health policy).Ever since the collapse of the once successful Rural Cooperative Medical System in the early 1980s, many rural communities, especially the poorer residents, have faced several major problems. User charges effectively blocked access for many rural residents who lack adequate income to purchase basic health care when needed. Impoverishment due to medical expenses is also a serious problem.The vicissitude of Cooperative Medical System can be explained with the theory of New Institutional Economics. The early flourishing of Cooperative Medical System was the result of institution equilibrium. The collapse of the once successful Rural Cooperative Medical System was due to inside dilemma and outside adverse environment, which led to disequilibrium. Because of the interactive of demand and supply, especially inadequate government policies, led to inadequate incentive for both induced and forced institution vicissitudes. These hindrances explain the lack of rural health insurance in the whole 1990s. Recently, the Chinese government announced a new rural health financing policy, which was a forced institution change in the new environment.Community financing can be seen as having three independent objectives: (a)
mobilizing financial resources to promote better health and to diagnose, prevent, and treat known illnesses;(b) protecting individuals and households against direct financial cost of illness when channeled through risk-sharing mechanisms;and (c) giving the poor a voice in their own destinies and making them active participants in breaking out of the social exclusion in which they are often trapped.According to this framework, Rural Cooperative Medical System has played a important role in risk sharing and financial protection. But with the model of low premium and high co-payment, it was somewhat unfair in acquiring the benefits for the poorer.The ability and willingness of rural farmers to pay contributions to Rural Cooperative Medical System is the basis for sustainable development. This thesis predicts the ability to pay with the extended linear expenditure system. It discovers that the poor cannot afford to pay. But for most of the farmers with middle or above income, willingness to pay is more important than ability to pay. The factor influencing willingness to pay includes trust for government, the ability of government, the amount of subsidy, social capital, the tradeoff between costs and benefits, risk sharing mechanism within a family and among families and some individual characteristics.This thesis discusses solutions to important incentive problems in Rural Cooperative Medical System which threaten their sustainability. In particular, three issues explored are adverse selection, moral hazard and provider-induced demand. Compulsory Rural Cooperative Medical System isn't justified at the moment. It can perhaps prevent adverse selection, but at the same time bring about moral hazard from administrators and providers. Household as unit of insurance doesn't always mitigates adverse selection problem and is not always appropriate, so the best way of providing incentives depends very much on the context, that is, on the characteristics of the target population and the health risk profile. At the same time, household as unit of insurance can bring about some unexpected outcomes, that is, hinders the development of cities.Co-payment can prevent moral hazards, but it also block access for health care, especially for the poor. Co-payment is needed as not financial cause but as incentive to prevent cost. Ex ante moral hazard problem can be circumvented through group insurance contract.Providers, knowing that their patients are covered by insurance, may also
encourage unnecessary utilization. Different payment mechanisms can prevent providers-induced demands. Appropriate payment ways should be chosen and institutional causes should be eliminated.Governments can take a lot of actions to facilitate the development, sustainability, and impact of Rural Cooperative Medical System. The subsidy for rural health protection substantially lags behind the appropriate level. To eliminate the big gap, government should transform to focus public services. It is also important to adjust intergovernmental fiscal relations.From the perspective of justice of Rawls, substantive freedom and capability of Amartya Sen, human rights, health entitlement and social security entitlement, a universal basic health protection system should be established. The thesis put forwards the framework of the universal basic health protection system.
经济体制改革以来农村卫生工作令人担忧,其主要原因在于健康保障机制缺失下的高额治疗费用障碍,疾病的经济风险增大。而疾病风险使农民陷入脆弱性,因此建立农村健康保障制度势在必行。
可以运用新制度经济学有关制度变迁的理论来分析合作医疗制度的变迁。合作医疗的早期繁荣是制度均衡的结果,合作医疗解体是在其内在矛盾的演化和外部环境的变化共同作用下,从均衡走向非均衡的结果。由于需求和供给的相互作用以及政府没有能够提供足够的支持,农村健康保障制度诱致性制度变迁和强制性制度变迁动力都不足,从而造成试图恢复合作医疗的努力并没有取得实质性的效果。新型农村合作医疗是政府在新的历史条件下主导的强制性制度变迁。
可以用资源动员、财务保障和社会包容的三维分析框架来评价社区健康融资(合作医疗)的绩效。农村合作医疗在风险分担和财务保障方面发挥了一定的作用,但在“低费用、高共付率”模式下,合作医疗受益存在着不公平性。
农民或农户是农村健康保障制度的需求主体,其需求状况,即其支付能力和支付意愿是合作医疗可持续发展的基础。通过扩展线性支出系统来测算农民或农户对合作医疗的支付能力,结果表明农村贫困人群存在支付能力的问题,但大多数中等收入以上的农民的主要问题是支付意愿。在国家层面上,影响支付意愿的因素主要是对政府的信任程度、政府的“机构能力”以及补贴的力度大小。社区层面的影响因素是社会资本。家庭对合作医疗的支付意愿主要取决于其对参保的成本和收益的比较,家庭风险分担机制和家庭之间风险分担机制也会对家庭的支付意愿产生影响。支付意愿还和农民的个人特征相关。
合作医疗实行强制并没有足够的合法性。强制投保可能防范了居民的“逆向选择”,但是却带来了管理人员和卫生服务提供者的“道德风险”。以家庭作为投保单位并不能绝对地增加参保人数,抑制逆选择,需要根据目标人群的具体特征
In the new Cooperative Medical System, the interactive among different related-interest groups or roles, such as providers, insured, fund and government agencies, jointly determines the efficiency of the system. The purpose of this dissertation is to analyze and discuss the behavior mechanism of related roles, demonstrate the challenges and dilemma, and further to discuss solutions to important incentive problems in which threaten their sustainability.Health financing has made important influence on the three goals of health systems: financial fairness, disability-adjusted life expectancy and responsiveness. Health financing involves risk pooling and resources pooling, which affects the use of health care for different income groups. The introduction of health insurance influences demand and supply and other variables. The growth of community-based health financing arrangements rests on developments in three related areas ,that is microfinance (microcredits, microsavings, microinsurance, financial intermediation), social capital (community, network, institutional, and societal links), mainstream theories (welfare of society, public finance, social policy, and health policy).Ever since the collapse of the once successful Rural Cooperative Medical System in the early 1980s, many rural communities, especially the poorer residents, have faced several major problems. User charges effectively blocked access for many rural residents who lack adequate income to purchase basic health care when needed. Impoverishment due to medical expenses is also a serious problem.The vicissitude of Cooperative Medical System can be explained with the theory of New Institutional Economics. The early flourishing of Cooperative Medical System was the result of institution equilibrium. The collapse of the once successful Rural Cooperative Medical System was due to inside dilemma and outside adverse environment, which led to disequilibrium. Because of the interactive of demand and supply, especially inadequate government policies, led to inadequate incentive for both induced and forced institution vicissitudes. These hindrances explain the lack of rural health insurance in the whole 1990s. Recently, the Chinese government announced a new rural health financing policy, which was a forced institution change in the new environment.Community financing can be seen as having three independent objectives: (a)
mobilizing financial resources to promote better health and to diagnose, prevent, and treat known illnesses;(b) protecting individuals and households against direct financial cost of illness when channeled through risk-sharing mechanisms;and (c) giving the poor a voice in their own destinies and making them active participants in breaking out of the social exclusion in which they are often trapped.According to this framework, Rural Cooperative Medical System has played a important role in risk sharing and financial protection. But with the model of low premium and high co-payment, it was somewhat unfair in acquiring the benefits for the poorer.The ability and willingness of rural farmers to pay contributions to Rural Cooperative Medical System is the basis for sustainable development. This thesis predicts the ability to pay with the extended linear expenditure system. It discovers that the poor cannot afford to pay. But for most of the farmers with middle or above income, willingness to pay is more important than ability to pay. The factor influencing willingness to pay includes trust for government, the ability of government, the amount of subsidy, social capital, the tradeoff between costs and benefits, risk sharing mechanism within a family and among families and some individual characteristics.This thesis discusses solutions to important incentive problems in Rural Cooperative Medical System which threaten their sustainability. In particular, three issues explored are adverse selection, moral hazard and provider-induced demand. Compulsory Rural Cooperative Medical System isn't justified at the moment. It can perhaps prevent adverse selection, but at the same time bring about moral hazard from administrators and providers. Household as unit of insurance doesn't always mitigates adverse selection problem and is not always appropriate, so the best way of providing incentives depends very much on the context, that is, on the characteristics of the target population and the health risk profile. At the same time, household as unit of insurance can bring about some unexpected outcomes, that is, hinders the development of cities.Co-payment can prevent moral hazards, but it also block access for health care, especially for the poor. Co-payment is needed as not financial cause but as incentive to prevent cost. Ex ante moral hazard problem can be circumvented through group insurance contract.Providers, knowing that their patients are covered by insurance, may also
encourage unnecessary utilization. Different payment mechanisms can prevent providers-induced demands. Appropriate payment ways should be chosen and institutional causes should be eliminated.Governments can take a lot of actions to facilitate the development, sustainability, and impact of Rural Cooperative Medical System. The subsidy for rural health protection substantially lags behind the appropriate level. To eliminate the big gap, government should transform to focus public services. It is also important to adjust intergovernmental fiscal relations.From the perspective of justice of Rawls, substantive freedom and capability of Amartya Sen, human rights, health entitlement and social security entitlement, a universal basic health protection system should be established. The thesis put forwards the framework of the universal basic health protection system.
引文
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