随着医疗保险制度改革的不断深入，基本医疗保险医疗待遇水平的差异性、不 公平性、医疗保险基金互济功能和承受风险能力差、医疗保险关系转移接续以及异 地就医等一系列问题一直困扰着全国医疗保险经办机构，而提高医疗保险基金的统 筹层次则能很好地解决这些问题。与此同时，国家第一次以法律的形式对社保基金 统筹层次做出了明确规定,《中华人民共和国社会保险法》中第六十四条规定:“基本 养老保险基金逐步实行全国统筹,其他社会保险基金逐步实行省级统筹,具体时间、步 骤由国务院规定。”这也充分体现出提高医保基金统筹层次的做法有法理依据。 在研究思路上，本研究通过归纳推理和演绎推理的方式，分析在全国逐步推进 覆盖全民的基本医疗保障体系的背景下，分析了兵团基本医疗保险师级统筹的现状， 阐述了兵团基本医疗保险师级统筹存在的问题、困难以及原因分析。之后，结合兵 团的实际情况，通过阐述兵团基本医疗保险制度演变历程及面临的历史机遇，对比 兵团各统筹区筹资水平和医疗待遇水平，找出共性，阐述兵团基本医疗保险实行省 级统筹的紧迫性、重要性和可行性，并得出兵团可以率先实现基本医疗保险省级统 筹。 根据研究得出以下五点主要研究结论， （1）提出了师级统筹的问题 包括师与师之间医疗待遇水平存在差异，造成参保人员之间的攀比引发矛盾； 基本医疗保险基金共济性差导致基金抵御风险的能力弱；基金使用效率得不到提高， 难以保证医疗服务的品质；医保关系转移接续难，阻碍了人才和富余劳动力的自由 流动；参保人员出现重复参保问题；实现公共政策价值目标的运行管理成本高。 （2）分析了问题原因 既有历史和社会经济成因也有现有政策体系架构的问题。一是兵团体制发展历 史导致的；二是各统筹区经济发展水平不平衡；三是各师参保人数相差较大；四是 统筹层级低不能有效提升基金使用率，效率低是必然的；五是统筹层次低会直接影 响到公共资源分配能力不足；六是统筹水平低导致大量重复参保和异地就医困难的 问题。VI （3）分析了兵团基本医疗保险省级统筹的可行性 首先分析了兵团基本医疗保险省级统筹的必要性。一是新医改革目标任务的需 要；二是保障参保人员医保权益和适应社会主义市场经济体制的客观要求；三是医 疗保险制度运行的现实需要；四是医疗保险制度走向成熟的标志。 然后分析了兵团基本医疗保险省级统筹具备的条件。一是兵团的特殊性；二是 各统筹区筹资和医疗待遇水平相差较小；三是参保人员的意愿提高；四是中央财政 资金补助提供必要保障。 （4）通过分析国内外医疗保险工作的经验和启示，分析实现省级统筹就可能遇 到的问题 通过国内外医疗保险工作的经验和启示，分析兵团在实行基本医疗保险省级统 筹的过程中可能遇到的问题和困难。 （5）给出了对策建议 针对梳理出的问题及原因分析，有针对性地提出了实现兵团基本医疗保险省级 统筹的对策建议，为进一步完善兵团医疗保险制度、提高基本医疗保险统筹层次提 供很好的借鉴作用。 关键词，医疗保险制度；改革；可行性； 省级统筹；兵团VII Abstract The medical insurance system in China has been conducting a continuous reformation for years. However, series of issues are hindering the implement and management for medical insurance agencies national wide. There are differences and unfairness on medical treatment levels among medical institutions in varies areas due to economical and social development status. The mutual aid function of medical insurance is inadequate and capability to withstand risks is not optimistic, either. Furthermore, the inefficiency in medical insurance transferring and medical treatment reimbursement among provinces are also huge challenge to the system. Whereas, a higher level pooling of medical insurance fund will provide a proper solution for the abovementioned issues, especially in Xinjiang Production & Construction Corps（.XPCC for abbreviation）, whose special organizational structure is more convenient to adopt to this new pooling system. Furthermore Article 68 of Law of Social Insurance in PRC indicates that the basic pension insurance fund can gradually realize a national pooling management system, and the other kinds of insurances will implement provincial level pooling of fund management step by step according to the schedule and procedures made by the State Council. This is the first time to clearly regulate the level of pooling management by law, which means that medical insurance fund can have higher level pooling. This research is based on the background of building system with a maximum coverage of population to insure basic medical insurance gradually national-wide. Through inductive and deductive reasoning, the status of basic medical insurance fund management in division level in XPCC is analyzed to reveal the issues, difficulties, and causes of this system as well. Then, the history of the basic medical insurance system and opportunities it faced is discussed thus to make a comparison on the fund raising and medical reimbursement level among the fifteen divisions of XPCC in order to find their similarities. After elaborating on the urgency, significance and feasibility of provincial level pooling on the management of basic medical fund in XPCC, a conclusion will be reached that it is possible to pioneering into a provincial level pooling for the medical insuranceVIII system in XPCC due to its special organizational structure. According to the above mentioned studies, five conclusions can be researched: (1)Has raised the issue in the Division level of pooling for medical insurance fund in XPCC There are differences in medical insurance reimbursement among divisions thus caused conflicts since the insurance appliers compare would compare that with each other. The mutual aid function of medical insurance is inadequate in the divisions and capability to withstand risks is not optimistic, either. The efficiency of fund usage cannot be improved and the quality of medical services is hard to guarantee. Difficulties in the transferring of medical insurance among provinces or districts have hindered the free flow for employment in different locations freely. For those issues, people will apply for medical insurance in several institutions. And it cost more to operate and manage the insurance system. (2)Analyzed the roots and causes There are historical, social and economical causes for the issues exposed in the medical insurance system in XPCC as well as its systematical status. First, issues have been existed in the development of the XPCC since its foundation. Second, it is uneven in economic development among divisions in XPCC. Third, there are huge differences about the number of insured population among divisions. Fourth, it is inevitable for the usage of the insurance fund to have lower efficiency in division level pooling. Fifth, capabilities of distribution on public resources are inadequate due to low level pooling of fund. Sixth, the number of population insuring in difference divisions is huge and reaching for medical treatment beyond the insured locations is hard for the same reason mentioned above. (3)Presented the feasibility for the XPCC to implement a provincial level pooling of medical insurance fund Necessity and background have been analyzed in this part. For the necessity, there are four aspects. Firstly it will meet the national goal of reformation in medical system in China. Secondly, it will satisfy the needs to secure the rights of insured group and adapt to the socialist market system. Thirdly, it reflects the objective needs for the management of medical insurance system. And lastly, itIX is a symbol for the mutuality of the medical insurance system. Four main conditions have been ready for the provincial level pooling in XPCC. They are the specialty of the system in XPCC, comparatively smaller difference among divisions in fund raising and reimbursement among divisions, increasing wills for insured group, and the financial aid provided by the central government. (4)By analyzing the experience of domestic and foreign medical insurance practices, problems that might encounter can be predicated for the implement of provincial level pooling of medical insurance fund in XPCC. (5)Solutions and Suggestions Possible solutions and suggestions are proposed to realize the provincial level pooling of medical insurance fund in XPCC based on the issues and analysis correspondingly. Hopefully, they can provide references for elevating the pooling level of medical insurance fund thus to make further development of the medical insurance system in XPCC. Key Words: Medical Insurance System, Reformation，Feasibility, Provincial Level of Fund Pooling， XPCCX 目 录 摘要.....................................................................................................................................................V ABSTRACT ..............................................................................................................................................VII 1 绪论 ...................................................................................................................................................... 1 1.1 研究目的及研究意义 ......................................................................................................................... 1 1.1.1 研究目的....................................................................................................................................... 1 1.1.2 研究意义....................................................................................................................................... 2 1.2 国内外研究现状综述 .......................................................................................................................... 2 1.2.1 国外研究现状............................................................................................................................... 2 1.2.2 国内研究现状............................................................................................................................... 2 1.2.3 研究评述....................................................................................................................................... 3 1.3 研究内容与方法 .................................................................................................................................. 4 1.3.1 研究内容及框架图....................................................................................................................... 4 1.3.2 研究方法及技术路线图............................................................................................................... 5 1.4 创新点.................................................................................................................................................. 5 2 相关概念和理论 .................................................................................................................................. 6 2.1 基本概念的界定 .................................................................................................................................. 6 2.1.1 基本医疗保险............................................................................................................................... 6 2.1.2 基本医疗保险基金省级统筹....................................................................................................... 6 2.2 相关理论.............................................................................................................................................. 7 2.2.1 医疗保险与疾病风险理论........................................................................................................... 7 2.2.2 医疗保险的供给与需求理论....................................................................................................... 7 3 兵团基本医疗保险统筹的现状和问题及原因分析.............................................................................. 8 3.1 兵团基本医疗保险师级统筹的现状 .................................................................................................. 8 3.2 兵团基本医疗保险师级统筹面临的问题 ........................................................................................ 10 3.2.1 存在的问题................................................................................................................................. 10 3.2.2 面临的困难和挑战..................................................................................................................... 10 3.3 兵团基本医疗保险基金师级统筹问题的原因分析 ........................................................................ 11 3.3.1 历史和社会经济成因................................................................................................................. 11 3.3.2 现有政策体系架构的问题......................................................................................................... 12 4 兵团基本医疗保险实行省级统筹的可行性分析................................................................................ 14 4.1 基本医疗保险实行省级统筹的必要性 ............................................................................................ 14 4.1.1 新医改革目标任务的需要......................................................................................................... 14 4.1.2 保障参保人员医保权益和适应社会主义市场经济体制的客观要求 ..................................... 14 4.1.3 医疗保险制度运行的现实需要 ................................................................................................. 15 4.1.4 医疗保险制度由不完善走向成熟 ............................................................................................. 15 4.2 具备的条件........................................................................................................................................ 15 4.2.1 兵团的特殊性............................................................................................................................. 15 4.2.2 各统筹区筹资和医疗待遇水平相差较小 ................................................................................ 17XI 4.2.3 参保人员的意愿提高................................................................................................................ 19 4.2.4 中央财政资金补助提供必要保障 ............................................................................................ 19 4.3 实现省级统筹的模式和思路 ............................................................................................................ 20 4.3.1 省级统筹的模式......................................................................................................................... 20 4.3.2 省级统筹的思路......................................................................................................................... 21 5 兵团基本医疗保险省级统筹可能遇到的问题 ................................................................................... 23 5.1 兵团实行省级统筹过程中可能遇到的障碍和问题........................................................................ 23 5.1.1 建立在经济发展水平基础上的医保政策带来的问题 ............................................................. 23 5.1.2 医保基金筹集标准的核定和跨区转移接续政策的影响 ......................................................... 23 5.2 国外医疗保险工作的经验与启示 .................................................................................................... 24 5.2.1 德国医疗保险工作的实践经验 ................................................................................................. 24 5.2.2 德国基本医疗保险统筹的启示 ................................................................................................. 26 5.3 国内基本医疗保险省级统筹的经验与启示 .................................................................................... 26 5.3.1 海南省基本医疗保险省级统筹经验 ......................................................................................... 26 5.3.2 海南省基本医疗保险省级统筹的启示 ......................................................................................27 6 兵团基本医疗保险实现省级统筹的对策和建议................................................................................ 31 6.1 对策.................................................................................................................................................... 31 6.1.1 不断完善医疗保险制度建设..................................................................................................... 31 6.1.2 进一步扩大医疗保险覆盖范围 ................................................................................................. 31 6.1.3 积极探索利用财政补助促进劳动力转移 ................................................................................. 31 6.1.4 做好不同社会保险制度的转移接续 ......................................................................................... 32 6.1.5 强化基金运行分析、监控和基金监督 ..................................................................................... 32 6.1.6 加强社会保险经办机构队伍能力建设 ..................................................................................... 32 6.1.7 积极争取中央财政加大对兵团的转移支付力度 ..................................................................... 33 6.2 建议.................................................................................................................................................... 33 6.2.1 完善兵团医疗保障体系............................................................................................................. 33 6.2.2 建立兵团级基本医疗保险调剂金制度 ..................................................................................... 33 6.2.3 建立兵团基本医疗保险待遇水平动态调节机制 ..................................................................... 33 7 结束语 ................................................................................................................................................ 34 7.1 主要研究结论 ................................................................................................................................... 34 7.1.1 提出了师级统筹的问题............................................................................................................. 34 7.1.2 分析了问题原因......................................................................................................................... 34 7.1.3 分析了兵团基本医疗保险省级统筹的可行性 ......................................................................... 34 7.1.4 分析省级统筹就可能遇到的问题 ............................................................................................. 35 7.1.5 给出了对策建议......................................................................................................................... 35 7.2 存在的不足之处 ............................................................................................................................... 35