中國新型農(nóng)村合作醫(yī)療制度淺析

1、中國新型農(nóng)村合作醫(yī)療制度淺析摘 要：現(xiàn)行經(jīng)濟條件下，我國農(nóng)村地區(qū)缺 乏有效的社會保障，因病致貧、因病返貧現(xiàn) 象十分突出。這些問題的存在，影響了農(nóng)民 健康狀況的改善，也影響了農(nóng)村經(jīng)濟社會的 長期穩(wěn)定發(fā)展。2003年起我國開始實行新型 農(nóng)村合作醫(yī)療制度，多年來改善了農(nóng)民看病 貧困的問題。但是，該項制度在實行過程中 仍然存在一些問題，這是不容忽視的。本文 則從四個方面簡析了新農(nóng)合面臨的問題，希望能對問題的日后解決有所幫助。關鍵詞：基礎道德風險逆向選擇資金籌 集法律法規(guī)以大病統(tǒng)籌為主的農(nóng)民醫(yī)療互助共濟制 度。主要是解決農(nóng)民看病窮、沒錢看病的問 題。該合作醫(yī)療基金主要用來補償參保農(nóng)民 的金額較大的醫(yī)療費

2、用或者住院費用。新型農(nóng)村合作醫(yī)療是我國政府第一次參與的合 作醫(yī)療制度，表明我國社會政策向從城市向 農(nóng)村的傾斜。新農(nóng)合自 2003在我國局部地 區(qū)試點以來，在政府的支持和推動下發(fā)展迅 速，并在一定程度上緩解了農(nóng)民看病費用問題。作為一項關系著廣大農(nóng)民健康的惠民政 策，新型農(nóng)村合作醫(yī)療還面臨著一些問題， 需要我們?nèi)ヌ接懭ソ鉀Q。（一）基礎不扎實我國新型農(nóng)村合作醫(yī)療制度以保大為 主，俗稱“保大不保小”，把主要精力放在 “大病統(tǒng)籌”方面。有人認為，新型農(nóng)村合 作醫(yī)療制度“保障目標定為保大病，事實上 放棄了對大多數(shù)人基本醫(yī)療需求的保障責 任”二 農(nóng)村缺醫(yī)少藥，這種現(xiàn)象自新農(nóng)合 開始試點以來并沒有得到根本性的

3、改善。很多實行新農(nóng)合的地方，依然有農(nóng)民生病了拖 著，導致最終拖成嚴重的疾病。在“保大不 保小”制度下，很多農(nóng)民會報銷醫(yī)藥費，小 病也去住院，小病按照花費大的方向去治療， 這也導致了醫(yī)療資源的浪費。 在廣大發(fā)達地 區(qū)，新農(nóng)合的根本性障礙不是經(jīng)濟問題，而 在廣大中西部地區(qū)，經(jīng)濟問題卻成為新農(nóng)合 發(fā)展的首要問題在對河南省汝州市溫泉鄉(xiāng) 側(cè)喔莊的調(diào)查中發(fā)現(xiàn)，2006年，該社區(qū)（村） 總?cè)丝?1080人，參保 708人，未參加 372 人，參合率為65.55%,低于全國2004年10月統(tǒng)計的72.6%,的平均參合率及汝州市 81.9%的參合率。在未參合的農(nóng)民中，除在 外打工和年輕者不愿參加外，其余的12戶

4、人家均屬經(jīng)濟問題。鄭縣堂街鎮(zhèn)退保的農(nóng)民 中67%歸因于經(jīng)濟原因"。這表明新農(nóng)合的 拓寬基礎的工作并沒有有效地落實。（二）“道德風險”和“逆向選擇”問 題突出新農(nóng)合的實施過程中存在著道德風險 問題。主要表現(xiàn)在：一些醫(yī)生為獲取回扣， 則常常通過多開些藥甚至開貴的藥給患者， 這給農(nóng)民消費了成本過高的醫(yī)藥，增加了其 肩上的醫(yī)療負擔，也造成醫(yī)藥資源的浪費。 還有一些定點醫(yī)院為追逐過多的利潤，提高醫(yī)療服務的收費，服務和醫(yī)藥的高價格也抵 消了新農(nóng)合給農(nóng)民帶來的優(yōu)惠，農(nóng)民的利益遭受到損害。逆向選擇的問題主要表現(xiàn)在： 往往是風險高的患者比風險低的患者更愿 意參加醫(yī)療保險。一些容易生病或者身體狀 況很不

5、佳的人群往往更傾向于參加新型農(nóng) 村合作醫(yī)療，而身體健康的人群參與的積極 性卻不高。同時，對參保農(nóng)民的費用控制目 前也缺乏一些有效的方法， 很多時候出現(xiàn)小 病大看，無病騙?，F(xiàn)象。這些逆向選擇一旦 產(chǎn)生，將對新農(nóng)合的可持續(xù)發(fā)展產(chǎn)生很不利 的影響。（三）籌資難度大資金籌集對于我國新型農(nóng)村合作醫(yī)療 保險來說是十分重要的，是保證其持續(xù)順暢 運行的基礎。就目前的情況來看，新農(nóng)合資 金的籌集在總體上看到位情況是不錯的，達到90%。揭開高到位率的面紗，隱含籌資的 可持續(xù)性問題又會浮現(xiàn)出來。新農(nóng)合實施過程中，有部分農(nóng)民雖有能 力但卻沒有繳費參加保險， 這可能由于新農(nóng) 合實施的年限不長，農(nóng)民對于它的前景還沒 有足

6、夠的看清楚，同時農(nóng)民對于很多干部及 政策也存在著不大信任的因素。 新農(nóng)合已經(jīng) 籌到的資金，好多是基礎執(zhí)行人員上門收取， 甚至采取談判的形式來籌集， 還有一部分甚 至采取強制性的措施。這樣籌資方式只能保 證一時能籌集到所要的資金，但對可預見的 未來能否持續(xù)籌集到穩(wěn)定的資金并不能起 保證作用。政策規(guī)定的籌集資金程序是一層一層 來的，中央補助資金是要在地方政府補助資 金到位后撥付，地方補助資金是在農(nóng)民交費 后再撥付。而由于農(nóng)民對地方政府存在著不 大信任的因素，很多時候不愿意先交錢，擔 心地方政府收費不透明，這樣籌集資金就不 大順利。一些基層干部為完成規(guī)定指標以追 求政績，強迫農(nóng)民參加新農(nóng)合，還強迫一

7、些 衛(wèi)生院和鄉(xiāng)村醫(yī)生代收費用。再者，基層出 現(xiàn)財政緊張時無法兌現(xiàn)對農(nóng)民的資金補助， 從而導致中央和上級財政撥款未能按時到 位。（四）法律法規(guī)不健全新農(nóng)合制度從試點到實行已經(jīng)有幾年 時間，但是目前國家還沒有將其納入強制實 施的法律范疇。國家有出臺國務院關于建 立新型農(nóng)村合作醫(yī)療制度的指導意見，但是還沒有一些具體的法律法規(guī)來指導新農(nóng) 合的實踐，使得人們對新農(nóng)合的認識并不能 達到統(tǒng)一。很多地方采取簽訂責任書的形式 以期加大基層干部參與合作醫(yī)療的責任心 和統(tǒng)一他們的思想，但是這些措施隨意性較大，也容易受到各種因素的干擾。同時，農(nóng) 民、醫(yī)療機構和政府和商業(yè)機構之間四方并 沒有建立起合同關系，農(nóng)民在權益受

8、到損害 時往往申訴無果，大大削弱了農(nóng)民參加新農(nóng) 合的積極性。政府、商業(yè)保險機構和慘加保 險的農(nóng)民三者之間的法律關系并不明確，商業(yè)保險在與政府簽訂委托協(xié)議時，與參加保 險的農(nóng)民之間也存在著某種程度上的關系。這樣，這三者之間的權利義務關系便不能合 理確定，這增加了商業(yè)保險機構參加新農(nóng)合 過程中的風險。再者，由于缺乏配套的政策 制度和法律法規(guī)，對于保險公司、政府和政 府主管機構之間權利、義務和責任無法區(qū)分 清楚，這也大大影響到保險公司參與保險的 積極性。參考文獻：1劉軍民.農(nóng)村合作醫(yī)療存在的制度缺 陷"N.華中師范大學學報.2006,(3):37-41.2王芹萼,新型農(nóng)村合作醫(yī)療的可持續(xù)

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48、red to the out -of-pocket systemThe China Quarterly, 181 (2005), pp. 137- 157IIK. Liu, W. FanThe analysis on fluctuation of cooperative medical scheme of two counties in Shanxi province in 1990'sChinese Health Economics, 21 (2002), pp. 14- 17 (in Chinese)Hsiao W. Plenary Session. Chinese Economi

49、sts Society Annual Conference, Chongqing, 2005 June 24.M. Lindelow, A. WagstaffHealth shocks in China: are the poor and uninsured less protected? World BandPolicy Research Working Paper (2005), p. 3740A. WagstaffThe economic consequence of health shocksWorld Bank, Policy Research Working Paper (2005

50、), p. 3644B. Gustafsson, S. LiExpenditures on Education and health care and poverty in rural ChinaChina Economic Review, 15 (2003), pp. 292- 301Ministry of Health (PRC). Research on national health services: an analysis report of the second national health service survey in 1998. Beijing; 1999 (in C

51、hinese).Y. Liu, K. Rao, W. HsiaoMedical expenditure and rural impoverishment in ChinaJournal of Health Population Nutrition, 21 (2003), pp. 216- 222IM. Liu, Q. Zhang, M. Lu, C.S, Kwon, H. QuanRural and urban disparity in health services utilization in ChinaMedical Care, 45 (2007), pp. 767- 774IIX. Z

52、hang, R. KanburSpatial inequality in education and health care in China China Economic Review, 16 (2005), pp. 189- 204III1997. HecAkin JS, Dow WH, Lance PM, L CA. Changes in access to health care in China, 1989 Policy 2005;20:80- 9.J. Gao, J. Qian, S. Tang, B. Eriksson, E. BlasHealth equity in trans

53、ition from planned to market economy in ChinaHealth Policy and Planning, 17 (2002), pp. 20- 29IIH.B. YinThe National Rural Health Conference was convened in Beijing People's Daily (2002 October 29)Y. WangDevelopment of the new rural cooperative medical system in ChinaChina & World Economy, 1

54、5 (4) (2007), pp. 66- 77IIY. LiuDevelopment of the rural health insurance system in ChinaHealth Policy and Planning, 19 (2004), pp. 159- 165LoadingS. BennettThe role of community -based health insurance within the health care financing system: a framework for analysisHealth Policy and Planning, 19 (

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