居民医疗负担和政府非盈利性健康保险.docVIP

居民医疗负担与政府非盈利性健康保险：国际经验 张琼 （清华大学经济管理学院） 摘要:居民（尤其是低收入居民）的医疗负担上升引起了各国政府和学者的广泛关注，许多国家一方面逐渐远离原有的公共医疗服务体系，通过工资税等的形式建立社会健康保险体系，从而为正式部门工人提供医疗保障；同时通过政府财政补贴等形式将低收入居民（尤其是非正式部门从业人员、弱势群体（如老人等健康风险较高的人群））不断纳入到社会健康保险体系当中，或者为这些人群提供额外的政府非盈利性健康保险方案（NPHIs），以扩大医疗覆盖范围、促进居民医疗服务使用等。然而就目前的情形而言，NPHIs尽管对各个国家的医疗服务市场（甚至劳动力市场等）产生了非常深远的影响，并促进了居民医疗服务的使用量，但一定程度上可能并未实现其引入初衷：目标人群覆盖不够，且不一定减少了居民尤其是低收??人群的医疗负担。 关键字：健康保险 覆盖率 医疗使用 医疗负担 Households’ Health Burden and Government’s Non-profit Health Insurances: International Comparison Abstract: Many governments and researchers have paid more and more attentions on households’ heavier health burden (especially for those with lower income). Hence government’s non-profit health insurances (NPHIs) are enjoying a revival in parts of the developed and developing world at the moment. Many countries especially low and middle income ones that have once relied largely on tax finance (and out-of-pocket payments) have introduced NPHIs or are thinking about doing so, and are making vigorous efforts to extend coverage to the informal sector employees and the vulnerable such as the poor and the old, and also are committing themselves to promote health care utilizations through NPHIs. Ironically, this revival is occurring at a time when these NPHIs definitely exert a rather profound influence on health care markets, even the labor markets, and watch more health care utilizations, while they maybe have not achieved their original intentions yet to some extent: it argues that the target groups are not sufficiently covered. The paper also argues that NPHIs do not definitely reduce households’ health burdens, especially those of the poor. Key words: NPHIs, coverage, health care utilization, health burden 引言 过去几十年间，许多国家医疗支出不断上升，一方面政府卫生支出面临着越来越大的财政压力，另一方面居民个人现金（out-of-pocket）支出也持续增加，居民尤其是中低收入阶层的医疗负担不断上升。低收入国家居民尤其是无保障人群的个人现金支出占总的医疗支出的比重非常高，许多国家这一比重超过50%（如中国），印度更是超过75%。因此，很多低收入国家逐渐在其医疗体系中引入政府提供或发起的公共非盈利性健康保险（NPHIs），以实现以下几个方面的初衷：1）通过补贴或无偿提供的方式将中低收入阶层、弱势群体（老人或儿童）纳入健康保险体系当中，从而扩大医疗服务的