《保险研究》20260401-《国外替代型商业健康保险的实践及其引发的思考》（李珍、蒋浩琛）

［摘   要］健康是优效品,是衡量社会经济发展水平的重要指标。由于商业健康保险市场普遍存在信息不对称问题,难以通过较小投入获得全民公平的健康保障,因而自20世纪90年代以来,为数不多的完全没有公共医疗保障制度或公共医疗保障制度覆盖不全的高收入国家,通过立法为商业保险注入部分社会属性,强制其替代公共医疗保障制度的部分功能,从而产生了“替代型商业保险”。医疗保障领域从此有了公共医疗保障、替代型商业保险以及商业保险三种性质的制度。本文以美国、瑞士和荷兰为例探讨了替代型商业保险产生与发展的实践,发现尽管政府做了许多努力,替代型商业保险仍然不能有效达成促进社会公平和提升资源配置效率的目标。在讨论我国居民医保筹资难以满足居民医疗保障需求时,因国际比较方法失当,较普遍的解决方案是借鉴西方国家模式,寄望通过商业保险填补这一具有社会属性的供需缺口。本文强调,我国实现全民覆盖、分散疾病风险且兼具收入再分配功能的医疗保障制度,只能依靠不断完善的社会保险制度,商业保险则应遵循市场的逻辑,满足人民群众多样化、差异化的保障需求,真正实现社会的归社会、市场的归市场。

［关键词］替代型商业健康保险；医保社商定位；基本医疗保险；公平医保；惠民保

［作者简介］李珍,武汉大学政治与公共管理学院教授；蒋浩琛(通讯作者),福州大学经济与管理学院副教授。

International Practices of Primary Private Health Insurance and Policy Implications

LI Zhen,JIANG Hao-chen

Abstract：Health is both a merit good and a key indicator of socioeconomic development. However,information asymmetries in the private health insurance market make it challenging to achieve equitable health protection with a relatively small input. Since the 1990s,a small number of high-income countries without a public health security system,or with incomplete public coverage,have introduced legislation to incorporate some social attributes into private health insurance,mandating private insurers to perform some functions traditionally undertaken by public health security systems. Thus,these countries have developed what may be termed “primary private health insurance”. As a result,there exists three systems in the medical security field,namely,the public health security system,primary private health insurance,and commercial insurance. Drawing on the experiences of the United States,Switzerland and the Netherlands,this paper examines the institutional emergence and evolution of primary private health insurance. Despite painstaking efforts of the government,it finds that this arrangement has struggled to reconcile social equity with resources allocation efficiency. This study is partly motivated by ongoing debates in China concerning the financing constraints of the Urban and Rural Residents’ Basic Medical Insurance scheme. In such discussions,incomplete international comparisons often lead to calls to expand commercial insurance in order to bridge perceived supply-demand gaps. However,this paper argues that universal coverage,effective risk pooling and income redistribution in China can only be sustained through continued strengthening of social insurance. Instead,commercial insurance,guided by market logic,should complement the system by addressing diverse and differentiated needs,truly drawing a clear line between the social sphere and the market sphere.

Key words：primary private insurance;positioning of social insurance and commercial insurance;basic medical insurance;equitable health insurance;Huiminbao