我国居民医保筹资与待遇衔接机制的公平性思考

Reflections on the Fairness of Connection Mechanism Between the Financing and Benefits of Residents' Medical Insurance in China

《“十四五”全民医疗保障规划》提出我国医疗保障事业的目标之一——建设公平医保。公平统一的社会医疗保障体系能缩小地区间以及群体间的就医待遇、医疗资源与健康状况上的差异,提升全体城乡居民的公平感和幸福感,对推动共同富裕有重要作用。本文在筹资遵循“以支定收”原则与待遇支付遵循“以收定支”原则相结合、总体收支平衡的基础上,针对8个实现居民医保省级统筹的行政区,运用医疗保险筹资模型中的成本估计模型和粗估法进行了筹资与待遇适配度及基金收支状态的测算,发现8个行政区目前总体上筹资与待遇的衔接匹配情况较差,不符合保费缴纳与待遇保障的一致性和公平性。对此提出以下完善建议:探索基金管理原则逐步向“以支定收”转变;完善缴费、待遇标准的动态调整机制,加强筹资与待遇相衔接;持续推进医保省级统筹,理清待遇保障范围及边界等。

The 14th Five-Year Plan for National Healthcare Security proposes one of the goals of China's medical security industry is to build fair medical insurance.A fair and unified social healthcare security system can narrow the differences in medical benefits,medical resources,and health status between regions and groups,enhance the sense of fairness and happiness of all urban and rural residents,and play an important role in promoting common prosperity.On the basis of combining the principle of “income according to expenditure” in fund-raising with the principle of “expenditure according to income” in benefits payment,and achieving overall income and expenditure balance,this article uses the cost estimation model and rough estimation method in the medical insurance fund-raising model to calculate the compatibility between fund-raising and benefits,as well as the fund income and expenditure,for eight administrative regions that achieve provincial pooling of resident medical insurance.It was found that the overall matching between fund-raising and benefits in the eight administrative regions is poor,which does not conform to the consistency and fairness of premium payment and benefits guarantee.The following suggestions for improvement are proposed such as exploring the gradual shift of fund management principles towards “income according to expenditure”,improving the dynamic adjustment mechanism for standards of premium payment and benefits,and strengthening the connection between fund-raising and benefits,continuously promoting provincial coordination of medical insurance,clarifying the scope and boundaries of benefits guarantee,etc.