中国新型农村合作医疗制度浅析

中国新型农村合作医疗制度浅析 摘 要：现行经济条件下，我国农村地区缺 乏有效的社会保障，因病致贫、因病返贫 现象十分突出。这些问题的存在，影响了 农民健康状况的改善，也影响了农村经济 社会的长期稳定发展。2003 年起我国开始 实行新型农村合作医疗制度，多年来改善 了农民看病贫困的问题。但是，该项制度 在实行过程中仍然存在一些问题，这是不 容忽视的。本文则从四个方面简析了新农 合面临的问题，希望能对问题的日后解决 有所帮助。 关键词：基础 道德风险 逆向选择 资金筹 集 法律法规 以大病统筹为主的农民医疗互助共济制 度。主要是解决农民看病穷、没钱看病的 问题。该合作医疗基金主要用来补偿参保 农民的金额较大的医疗费用或者住院费用。 新型农村合作医疗是我国政府第一次参与 的合作医疗制度，表明我国社会政策向从 城市向农村的倾斜。新农合自 2003 在我国 局部地区试点以来，在政府的支持和推动 下发展迅速，并在一定程度上缓解了农民 看病费用问题。作为一项关系着广大农民 健康的惠民政策，新型农村合作医疗还面 临着一些问题，需要我们去探讨去解决。 （一）基础不扎实 我国新型农村合作医疗制度以保大为 主，俗称“保大不保小” ，把主要精力放在 “大病统筹”方面。有人认为，新型农村 合作医疗制度“保障目标定为保大病，事 实上放弃了对大多数人基本医疗需求的保 障责任”“，农村缺医少药，这种现象自新 农合开始试点以来并没有得到根本性的改 善。很多实行新农合的地方，依然有农民 生病了拖着，导致最终拖成严重的疾病。 在”保大不保小”制度下，很多农民会报 销医药费，小病也去住院，小病按照花费 大的方向去治疗，这也导致了医疗资源的 浪费。在广大发达地区，新农合的根本性 障碍不是经济问题，而在广大中西部地区， 经济问题却成为新农合发展的首要问题在 对河南省汝州市温泉乡侧崆庄的调查中发 现，2006 年，该社区（村）总人口 1080 人，参保 708 人，未参加 372 人，参合率 为 65.55%, ，低于全国 2004 年 10 月统计 的 72.6%, 的平均参合率及汝州市 81.9%的 参合率。在未参合的农民中，除在外打工 和年轻者不愿参加外，其余的 12 户人家均 属经济问题。郏县堂街镇退保的农民中 67% 归因于经济原因“。这表明新农合的拓宽基 础的工作并没有有效地落实。 （二） “道德风险”和“逆向选择”问 题突出 新农合的实施过程中存在着道德风险 问题。主要表现在：一些医生为获取回扣， 则常常通过多开些药甚至开贵的药给患者， 这给农民消费了成本过高的医药，增加了 其肩上的医疗负担，也造成医药资源的浪 费。还有一些定点医院为追逐过多的利润， 提高医疗服务的收费，服务和医药的高价 格也抵消了新农合给农民带来的优惠，农 民的利益遭受到损害。逆向选择的问题主 要表现在：往往是风险高的患者比风险低 的患者更愿意参加医疗保险。一些容易生 病或者身体状况很不佳的人群往往更倾向 于参加新型农村合作医疗，而身体健康的 人群参与的积极性却不高。同时，对参保 农民的费用控制目前也缺乏一些有效的方 法，很多时候出现小病大看，无病骗保现 象。这些逆向选择一旦产生，将对新农合 的可持续发展产生很不利的影响。 （三）筹资难度大 资金筹集对于我国新型农村合作医疗 保险来说是十分重要的，是保证其持续顺 畅运行的基础。就目前的情况来看，新农 合资金的筹集在总体上看到位情况是不错 的，达到 90%。揭开高到位率的面纱，隐 含筹资的可持续性问题又会浮现出来。 新农合实施过程中，有部分农民虽有 能力但却没有缴费参加保险，这可能由于 新农合实施的年限不长，农民对于它的前 景还没有足够的看清楚，同时农民对于很 多干部及政策也存在着不大信任的因素。 新农合已经筹到的资金，好多是基础执行 人员上门收取，甚至采取谈判的形式来筹 集，还有一部分甚至采取强制性的措施。 这样筹资方式只能保证一时能筹集到所要 的资金，但对可预见的未来能否持续筹集 到稳定的资金并不能起保证作用。 政策规定的筹集资金程序是一层一层 来的，中央补助资金是要在地方政府补助 资金到位后拨付，地方补助资金是在农民 交费后再拨付。而由于农民对地方政府存 在着不大信任的因素，很多时候不愿意先 交钱，担心地方政府收费不透明，这样筹 集资金就不大顺利。一些基层干部为完成 规定指标以追求政绩，强迫农民参加新农 合，还强迫一些卫生院和乡村医生代收费 用。再者，基层出现财政紧张时无法兑现 对农民的资金补助，从而导致中央和上级 财政拨款未能按时到位。 （四）法律法规不健全 新农合制度从试点到实行已经有几年 时间，但是目前国家还没有将其纳入强制 实施的法律范畴。国家有出台国务院关 于建立新型农村合作医疗制度的指导意见 ， 但是还没有一些具体的法律法规来指导新 农合的实践，使得人们对新农合的认识并 不能达到统一。很多地方采取签订责任书 的形式以期加大基层干部参与合作医疗的 责任心和统一他们的思想，但是这些措施 随意性较大，也容易受到各种因素的干扰。 同时，农民、医疗机构和政府和商业机构 之间四方并没有建立起合同关系，农民在 权益受到损害时往往申诉无果，大大削弱 了农民参加新农合的积极性。政府、商业 保险机构和惨加保险的农民三者之间的法 律关系并不明确，商业保险在与政府签订 委托协议时，与参加保险的农民之间也存 在着某种程度上的关系。这样，这三者之 间的权利义务关系便不能合理确定，这增 加了商业保险机构参加新农合过程中的风 险。再者，由于缺乏配套的政策制度和法 律法规，对于保险公司、政府和政府主管 机构之间权利、义务和责任无法区分清楚， 这也大大影响到保险公司参与保险的积极 性。 参考文献： 1刘军民.农村合作医疗存在的制度缺 陷“N.华中师范大学学报 .2006,(3):37-41. 2王芹萼.新型农村合作医疗的可持续 发展支持探讨J.消费导刊,2008(2):38-39. 3韩留富.试论新型农村合作医疗制度 可持续发展的对策J.北方经济,2006,(2):11- 12. 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