摘要 农村合作医疗与农村医疗救助是农村医疗保障体系中两种基本的制度或机制。自2003年7月开始，全国开展了农民自愿参加，由中央财政、地方财政和农民共同筹资，以大病补助为主的新型农村合作医疗试点工作。自2004年开始，全国开始建立政府拨款和社会各界自愿捐助等多渠道筹资，对患大病农村五保户和贫困农民家庭实行医疗救助的制度。在我国发生深刻的结构转型、农村卫生工作大力开展的背景下，及时总结与探讨已有工作的经验与问题无疑对更好地开展农村卫生工作有重要意义。医疗保障体系的基本功能是缓解健康风险对农户的打击，以防止或减少因病致贫、因病返贫现象。本文则着力讨论我国农村医疗保障体系在应对农户健康风险冲击方面的作用。具体地，本文主要研究了以下几方面问题： （1）讨论农户健康风险冲击，离不开对被调查者健康状况的判断或度量。本文首先尝试提出一种新的综合健康指标，借以反映被调查者的一般健康状况。具体方法是：根据已有数据结构先将8个健康自答指标分成4类指标组合，为每类指标组合定义健康状态集，在每个健康状态集上定义一个反映健康状况优劣的次序，再在每个健康状态集上定义一个恰当的实值函数，以严格反映该次序，每个实值函数即每类指标组合的类指标。利用调查数据，以自评类指标对其他三个类指标的线性回归估计结果作为这三个类指标的权重，求和后得到最终的综合健康指标。 （2）在农户状态变换的框架下，运用微观经济学消费者行为理论，讨论医疗保障体系在各种条件下缓解农户健康风险冲击的作用，揭示背后的经济学原理；并基于此探讨医疗保障体系的不同形式与原则。 （3）在了解苏州地区农村合作医疗历史沿革的基础上，以苏州市3县的605个农户（2004年情况）为样本，从经验上考察农村合作医疗在缓解农户健康风险冲击方面的作用。从中发现，健康而非收支类因素，是合作医疗参加户获得补偿、愿意继续参加合作医疗、生病条件下愿意就医的主要影响因素，即合作医疗在农户医疗行为方面强化了健康类因素的作用，削弱了收支类因素的作用，缓解了农户的融资约束，从而发挥了应对健康风险的作用。同时，合作医疗对于低收入组有特别重要的意义：虽然低收入组面临最严重的健康风险冲击，但合作医疗对这些户的风险冲击的缓解也是最大的。村卫生室、乡镇卫生院成为农户就医的主要地点。对于许多普通消费品而言，农户是否参加合作医疗，是否获得补偿，消费结构变化不大，但消费数量存在较大差异。参加合作医疗的农户及个人，其收入水平与其健康显著相关，从而，合作医疗能否很好地维护农户健康，直接关系到农户收入能力的高低。 （4）以世界银行贷款卫生VIII项目之农村特困医疗救助项目开展地区中的3省6县的1206个农户（2004年情况）为样本，运用各种描述性统计及二值logit模型从经验上考察农村医疗救助应对贫困人群健康风险冲击的作用，以及医疗救助覆盖的准确性问题。结论是，3个调查省医疗救助总体的制度安排与制度实施基本符合医疗救助项目的宗旨，但各省在具体实施上也各有侧重，有的省份在部分环节的实施上也出现了偏离。3个调查省的医疗救助覆盖都显著考虑了健康、人均劳动现金收入、家中是否有儿童三个因素；并且，医疗救助覆盖人群中存在一定比例的非贫困户；山西省的医疗救助覆盖并没有显著偏向最贫困的人群。此外，部分非贫困人群享有了相当大一部分补偿额，医疗救助补偿的力度仍然与农户收入有较大关系，没有呈现明显的有利于贫困人群的偏倚，贫困人群实际享受的医疗救助补偿还相对有限。因此，区分政策目标、细化救助规则、甄别救助对象方面还有待改进。 关键词：健康 风险冲击 合作医疗 医疗救助 Abstract Cooperative medical scheme (CMS) and medical financial aid (MFA) are two basic institutional arrangements of rural medical security systems. Since July, 2003, The pilot programs of the new rural cooperative medical scheme have been implemented in China, and in 2004, Chinese government began the building of the rural medical financial aid system. Since there have been profound socieoconomic changes in China and great improvements in China’s rural health services, it is important to review the lessons of past achiements for improving future rural health services. The medical security systems’ basic function is to relieve the shocks of health risks on rural housholds, which could reduce the possibilities of rural housholds becoming poor or poor again for diseases. This paper will discuss how China’s rural security systems relieve the shocks of rural housholds’ health risks. In detail, the main issues discussed are as follows: (1) Health measurement is necessary to discuss the shocks of health risks on rural housholds. This paper tries to develop a new general healt indicator to show the general health status of one person. Based on the data structure, the eight self-reporting health indices are divided into four categories of indices, and each category of indices has a defined health state set, on which both an order and an appropriate real-valued function are defined such that the function could strictly show the order. So each real-valued function is a category index of each category of indices.The general health indicator is the weighted sum of the three category indices, where the weights are determined by the estimation results of the regression of the self-rating category index on the other three self-reporting category indices. (2) In the framework of state-contingent transfer, this paper discusses the medical security systems’ function under different conditions by macroeconomic consumer theory, based on which it discusses the different institutional arrangements and the principles. (3) Based on the knowledge of the history of Suzhou’s rural cooperative medical scheme, this paper makes an empirical study on the rural CMS’s function, by the data of Suzhou. We find health, rather than income, are significant for rural households’ medical behaviors, which shows CMS relieve the households’ financial restrictions, especially for low-income households, which are shocked most seriiously by health risks but are compensated most. Village clinics and town hospitals are households’ first choice when suffering diseases. For some goods, households’ consumption structure is almost not affected by CMS participation or compensation, while the consumption quantitity is. CMS households’ or persons’ income are significantly related to health, so CMS’s protection of health is important for households’ income. (4) By the data of H8/H8SP MFA districts, this paper empirically studies how MFA helps the poor when suffering health risk shocks, and the coverage accuracy of MFA, by descriptive statistics and logit models. It concludes that the arrangement and the implementation of MFA in the three provinces accords with the general principles of the H8/H8SP in essence, but each province has its own focus in the project implementation and some provinces have even departed from the principle in some parts. MFA coverage in the three provinces are all significantly related to health, per-capita labor cash income and children; there are some non-poor households which receive medical aid; in addition, MFA coverage in Shanxi is not favorable to the poor significantly. Besides, some non-poor household receive much compensation. Government might make certain policy goals, subsidy rules and the qualification affirmation. Key Words: Health; Risk Impact; Cooperative Medical Scheme; Medical Financial Aid 目录 第一章 导言 1 一、研究背景 1 二、相关文献回顾 2 三、本文结构 3 四、相关变量的定义及说明 3 第二章 关于健康指标的讨论与设计 6 一、引言 6 二、关于健康指标设计的一种讨论 8 三、结合调查数据的计算 13 第三章 医疗保障机制应对健康风险冲击的作用 16 一、存在健康风险条件下农户状态变换的一般分析 16 二、存在健康风险条件下医疗保障机制的作用 18 三、医疗保障机制的形式与原则探讨 22 第四章 合作医疗与农户健康风险冲击 24 一、苏州地区农村合作医疗制度的历史沿革 24 二、苏州地区当前新型农村医疗保障制度安排简介 27 三、调查的一般情况 30 四、参加CMS的影响因素分析 33 五、CMS户获得补偿的影响因素分析 37 六、医疗支出与CMS补偿 41 七、CMS户继续参加CMS意愿的影响因素分析 44 八、就医意愿及其影响因素分析 49 九、就医方式选择 50 十、合作医疗与家庭支出结构 51 十一、收入与健康的关系 55 十二、结论 68 十三、附录 68 第五章 医疗救助制度与农户健康风险冲击 71 一、本研究的背景 71 二、关于本次调查的一般情况的介绍 72 三、卫生VIII项目及H8SP特困人口医疗救助的制度安排 72 四、MFA实际覆盖与补偿情况 75 五、MFA覆盖户资格认定的实际因素 83 第六章 总结 88 参考文献 90 后记 92