| 摘要: | 就作為一個公共政策的研究者而言，對於研究政治制度轉軌進程中的中國大陸，不得不關注其醫療保險政策的變革，因為它涉及到公共財政、民政救濟、醫療衛生、社會保障等多個部門及領域；相較於國防、外交、環境等政策，其間的利益考量更為廣泛，是從事公共政策研究者的良好課題、也是集大成者。
另一方面，也可以透過這個內涵極其豐富的醫療保險政策，來管窺中國大陸更為一般的公共政策的相關情狀，從而達到以小見大、由具體到一般的學術研究目標。然而面對一個龐大的人口群體，要「面面俱到」的研究它的醫療保險制度，實難以周全和深入，因此本文選擇了適用於農民群體的「新農合」作為研究對象，因最新統計資料顯示著，農民群體目前仍佔了全大陸地區總人口數約70.86%。
本文一開始先找出造成中國大陸「看病難、看病貴」的政策原因，再探討醫療保險政策本身存在的缺漏與「看病難、看病貴」的現況之間存在的因果關係；進而藉由新農合政策系統中的「供方」、「需方」及「協力廠商﹙經辦方﹚」三類核心主體，與新農合政策系統中的「醫療保險子系統」、「醫療基金子系統」及「醫療服務子系統」三個核心子系統進行有機的結合加以研究，力圖展現出政策缺漏與「看病難、看病貴」的完整因果鏈條；最終期待本文能兼具一定的理論意義與實務價值。
研究的結果，筆者發現新農合政策實施至今仍有「需方承擔的醫療費用並未降低」、「供方因基金額度『吃緊』推諉病人」及「經辦機構疊床架屋效率低下」等問題浮出水面尚待解決。本文建議解決以上各類問題的方法如下：
一、在「需方」的根本改變。如：
﹙一﹚參合農民醫療健康觀念的轉變。
﹙二﹚適當提高自付額的比例。
﹙三﹚適當提高個人籌資比例。
二、在「供方」的根本改變。如：走市場化及民營化道路
三、在「協力廠商」的根本改變。如：
﹙一﹚加快發展商業醫療保險。
﹙二﹚引入商業保險公司經辦新農合業務。
﹙三﹚提高新農合的統籌層次。
此外，建議參考臺灣地區的全民健保並與之對照來進行整合。相較於臺灣地區的全民健保，大陸地區的新農合、城職保、城居保：
一、可以考慮實行「強制參保」。
二、同全民健保一樣需要引導需方的「就醫觀念」。
三、比照全民健保，可以考慮實行全大陸地區的「統一醫保」。
至於有關新農合未來的整合，本文認為可採以下途徑，即：
一、儘快將新農合、城職保、城居保三項醫保納入同一政府管理部門，降低政策
運行的管理成本。
二、可以先與城居保整合，然後再與城職保整合。
至於本文的研究成果，如下：
一、全面、系統、深入地研究中國大陸新農合政策。
二、首次將三方均衡理論的方法運用於新農合政策分析之中。
三、將新農合政策的核心內容精煉為三類子系統中的三方關係。
四、提出優化新農合政策功能的路徑。
最後，在此要表達與強調的是：就研究政治制度轉軌進程中的國家或地區的公共政策而言，中國大陸的醫療保險議題可視為是研究公共政策之集大成者。因此，同樣處在由計劃經濟體制過渡到市場經濟的幾個東歐發展中國家甚或其他國家，他們在衛生部門呈現的問題及相應的政策變革也同會是公共政策學人極佳的研究課題。然因基於本文聚焦在中國大陸新農合的研究，所以筆者對之僅在研究背景的篇幅裡簡略提及東歐的部分，期待他日能見到學界的同好對此類議題會有更多的觀察與研究。
As a public policy researcher of Mainland China for the author of this thesis, the selection of social medical insurance﹙SMI﹚ system as the thesis topic has the following reasons. Firstly, the reforming of SMI system of Mainland China, in particular during the transition of political system, can involve a wide range of public territories such as public finance, civil administration relief fund, public health care, social security, etc.. and can induce a wider range of conflicting interest among different public sectors, in comparison to the policy-makings of national defense, foreign affairs, environment etc., thus, being a good research topic for the public policy research.
Secondly, the author intends through the research of medical insurance policy having abundant contents, to present the general condition of public policy of Mainland China, so to fulfill the in-depth analysis requirement of academic research. However, under the limited live data which could be collected, the clear presentation of the every aspect of medical insurance policy of Mainland China is a very difficult task. Hence, the author selects the New Rural Cooperative Medical Scheme﹙NRCMS﹚ which is applicable to the agriculture sector of Mainland China as the research topic. It is because, according to the recent statistics, farmers occupy 70.86% of the total population of Mainland China.
The thesis begins with finding the system reasons for the present medical status in Mainland China, i.e., being difficult and expensive to get medical treatment. Then these system reasons mainly caused by the pitfall of medical insurance policy are further investigated. For a further clarification, the core stakeholder entities and the three core operation subsystems, both of the NRCMS , as well as their interactions are presented. The three core stakeholder are： the medical service provider、 the medical service user and the cooperative venders； the three entities subsystems are： the medical insurance subsystem, the medical funding subsystem and the medical service subsystem. By analyzing the interaction among the three core stakeholders entities and with the three core subsystems, the author intends to clarify the causal chain between the policy pitfall and the present medical status of Mainland China.
The research results show that after implementation of the NRCMS, there are now still several problems to be solved, such as “medical cost on users not decreased”、“the service offered by providers shrinks due to limited medical funding”、“the lower efficiency due to the unnecessary overlapping of organization layers”. To solve the above problems, the author suggests：
1.The fundamental changes on medical users, such as：
﹙1﹚changing the medical health concept of farmers；
﹙2﹚properly increasing the percentage of self-payment for the medical
service；
﹙3﹚properly increasing the proportion of fund collected from medical users.
2. The fundamental changes on service providers, e.g., moving towards privatization and deregulation,.
3. The fundamental change on cooperative vendors, such as
﹙1﹚Speeding up the development of commercial medical insurance﹙CMI﹚；
﹙2﹚Encouraging the CMI companies to take charge of the NRCMS business；
﹙3﹚Lifting up the government level for a better coordination among various subsystems of NRCMS.
Furthermore, the author suggests referring to the National Health Insurance (NHI) of Taiwan and making a comparison between the NHIS and the NRCMS,. The NRCMS of Mainland China,
1. May consider to conduct the “forced participation”；
2. Should guide the service users¢ medical concept, in the same way as the NHI；
3. May consider to integrate the different medical insurance systems presently existing in Mainland China.
As to the future integration of NRCMS, the author suggests implementing the following policies：
1.Combing the existing three medical insurance systems：the NRCMS , the Urban Employee Basic Medical Insurance (UEBMI) and the Urban Resident Basic Medical Insurance (URBMI), as soon as possible, to be under one single governmental department to lower down the administrative cost；
2. Combining the NRCMS with the URBMI first, and then with the UEBMI.
The contribution of this thesis can be summarized as follows：
1 .Investigating the NRCMS from all possible aspects in a systematic and in depth
approach；
2. First time applying the three-aspect equilibrium theory to the policy analysis of NRCMS；
3. Highlighting the core contents of NRCMS as the interaction among three types of stakeholders with the three operation subsystems.
Finally, the research results of this thesis could be extended into the analysis of medical policy reform of the developing countries, in particular of Eastern Europe, which are under the same transition from planned economy into free-market economy as in Mainland China. Consequently, the policy reform research of these countries is highy encouraged for future study. As this thesis has been focused on the NRCMS of Mainland China, insufficient attention has been paid to the medical insurance policy reform of the developing countries in Eastern Europe, only limited presentation has been given as part of the literature survey. Facing with the high value of Eastern Europe research or the medical insurance policy reform, the author expects more studies by researchers in this area. |
