卫生财政学概念的涵义、范围领域、基本特征与地位作用(中)

3卫生财政的基本范围、内容和战略性研究议题 我们在本文中主要使用卫生财政的概念，研究卫生财政的范围、研究领域和战略性议题。我们已简要讨论了界定医疗财政、公共卫生财政和卫生保健财政与卫生财政学概念的内涵外延。由于我国卫生行业的习惯用法，尤其是汉语中“健康财政学”的说法容易引起人们的误解，     

卫生财政学概念的涵义、范围领域、基本特征与地位作用(下)

医疗财政、公共卫生财政、卫生保健财政与卫生财政体系是公共财政体系重要组成部分。属于社会福利财政范畴．是公共政策、社会政策与卫生政策框架的基础部分．是社会市场体系与社会基础结构体系的重要组成部分．在促进经济社会协调均衡稳定可持续发展和提高综合国力．全面实现小康社会和构建和谐社会中发挥基础性作用．在公共财政与社会福利财政体制建设中处于先导性、基础性、     

The Fiscal Consequences Attributed to Changes in Morbidity and Mortality Linked to Investments in Health Care: A Government Perspective Analytic Framework

Governments have an enormous economic and political stake in the health of their populations. Population health is not only fundamental to economic growth but also affects short-term and long-term government expenditure on health care, disability, and other social programs and influences direct and indirect tax receipts. Fiscal transfers between citizen and state are mostly ignored in conventional welfare economics analyses based on the hypothesis that there are no winners or losers through transference of wealth. However, from the government perspective, this position is flawed, as disability costs and lost taxes attributed to poor health and reduced productive output represent real costs that pose budgetary and growth implications. To address the value of health and health care investments for government, we have developed a fiscal health analytic framework that captures how changes in morbidity and mortality influence tax revenue and transfer costs (e.g., disability, allowances, ongoing health costs). The framework can be used to evaluate the marginal impact of discrete investments or a mix of interventions in health care to inform governmental budgetary consequences. In this context, the framework can be considered as a fiscal budget impact and/or cost-benefit analysis model that accounts for how morbidity and mortality linked to specific programs represent both ongoing costs and tax revenue for government. Mathematical models identical to those used in cost-effectiveness analyses can be employed in fiscal analysis to reflect how disease progression influences public accounts (e.g., tax revenue and transfers).     

Improvements in Health Status after Massachusetts Health Care Reform

Context

Massachusetts enacted health care reform in 2006 to expand insurance coverage and improve access to health care. The objective of our study was to compare trends in health status and the use of ambulatory health services before and after the implementation of health reform in Massachusetts relative to that in other New England states.

Methods

We used a quasi-experimental design with data from the Behavioral Risk Factor Surveillance System from 2001 to 2011 to compare trends associated with health reform in Massachusetts relative to that in other New England states. We compared self-reported health and the use of preventive services using multivariate logistic regression with difference-in-differences analysis to account for temporal trends. We estimated predicted probabilities and changes in these probabilities to gauge the differential effects between Massachusetts and other New England states. Finally, we conducted subgroup analysis to assess the differential changes by income and race/ethnicity.

Findings

The sample included 345,211 adults aged eighteen to sixty-four. In comparing the periods before and after health care reform relative to those in other New England states, we found that Massachusetts residents reported greater improvements in general health (1.7%), physical health (1.3%), and mental health (1.5%). Massachusetts residents also reported significant relative increases in rates of Pap screening (2.3%), colonoscopy (5.5%), and cholesterol testing (1.4%). Adults in Massachusetts households that earned up to 300% of the federal poverty level gained more in health status than did those above that level, with differential changes ranging from 0.2% to 1.3%. Relative gains in health status were comparable among white, black, and Hispanic residents in Massachusetts.

Conclusions

Health care reform in Massachusetts was associated with improved health status and the greater use of some preventive services relative to those in other New England states, particularly among low-income households. These findings may stem from expanded insurance coverage as well as innovations in health care delivery that accelerated after health reform.     

中国医疗卫生:挑战与出路

疾病风险可以引发经济风险、社会风险甚至政治风险。国内外都对疾病风险的防范给予高度重视,很多国家通过制度为百姓提供医疗保障,化解由疾病风险引发的其他风险。通过对中国疾病风险严重程度的分析,指出“看病难、看病贵”问题的核心原因是政府公共服务职能的缺失,这种缺失表现为社会保障制度的缺失和医疗公共筹资制度的弱化。为此,在发展战略选择上,主张选择以健康为核心的发展战略,以改革推动事业发展。在改革路径选择方面,提出以筹资模式的转变为突破口,促进医疗卫生服务管理模式、服务模式以及就医模式的转变。从而,全面实现推动以健康为核心的发展模式。     

卫生事业公益性与福利性定性的本质区别是什么

卫生政策和医学基础理论研究,医疗卫生的现实发展困境,医疗卫生体制改革,重构宏观卫生政策框架和构建和谐社会,"不约而同"共同聚焦医疗卫生服务"公益"性质。社会问题的"定性"至关重要,性质将直接决定服务对象、服务范围、服务内容、资金来源和服务方式,决定国家、市场互动关系和社会边界,决定社会资源分配模式和国家社会责任。虽然公益性与福利性存在许多相同之处,但是公益性与福利性存在诸多本质性差别和不同,卫生服务正确性质应是"福利性",而非"公益性",更不是"一定福利政策的社会公益事业"。     

公共财政框架下公共卫生账户体系的构建

探讨在公共卫生纳入公共财政的基本背景下公共卫生账户体系的构建,着重阐明公共财政框架下公共卫生账户体系的构建符合我国公共财政与公共卫生互动现状和协调发展的要求,是近阶段我国卫生账户体系进一步在省及省以下水平的推广应用,是服务于政府决策的难得机遇和重要催化剂,从方法学的角度剖析了公共财政框架下,公共卫生账户体系的构建相对于卫生账户体系构建的共性和个性特点。     

意大利医疗保障体系建设及启示

目的:意大利医疗卫生保健体系被认为是世界上最先进的体系之一,在医疗卫生和改善国民健康状况方面取得了良好的绩效.在我国当前深化医药卫生体制改革的背景下,结合我国实际情况,分析意大利卫生保健体系的经验和对于我国的医改工作的启示.方法:从意大利医疗保健体系的总体绩效介绍入手,着重分析意大利医疗保健体系的组织结构、医疗服务运作模式和筹资分配方式等方面,系统介绍意大利卫生保健体系的一些特点和富有成效的措施.结果:意大利医疗保障体系在组织结构、服务提供、筹资模式和药品管理体系方面都有一些值得肯定的做法.结论:意大利医疗卫生保健体系良好绩效的取得,对于我国新医改政策背景下的医疗卫生保健体系建设具有很好的启示.     

建设覆盖城乡居民的基本卫生保健制度的内涵和条件

通过对基本卫生保健制度的性质、内涵和条件介绍及对国内、国际有关基本卫生保健制度的定义收集,揭示出每一国民都有权利获得基本的医疗保障和卫生保健的服务,城乡的居民都应该享受到“基本卫生服务包”。然而,我国迄今尚未建立起一个真正的、覆盖城乡居民的、基本的卫生保健制度。通过对未来社会医疗保障、新型农村合作医疗与城市社区卫生服务发展方向的讨论,为增加政府的投资和公共财政支出计划建议如下:到2010年,卫生总费用支出应达到6%GDP,个人支出占卫生总费用的比例应减少至40%以下,政府预算卫生支出应占财政支出的6%～8%,新增比例至少要达到GDP的1%～2%。     

公共财政框架下县乡财政卫生支出优先次序下降的原因分析

通过分析财政改革与发展的历程,阐明了财政体制正在向公共化方向迈进;通过分税制背景下县乡财政的资金流程和收支结构分析阐明了在财力不足、转移支付制度不完善、财权与事权不对称和拉动经济发展的责任下,县乡财政压缩对社会事业的支出成为现实条件下的必然选择。在此基础上着重分析了卫生行业的特殊性、卫生部门和财政部门对卫生事业发展认识的不一致和卫生部门不理解财政改革基本逻辑和发展规律等是导致目前卫生支出在社会事业支出次序下降的原因。     

英国政府规制及卫生改革的特点与经验

从英国公共部门政府规制改革的实践看,成功规制的前提条件主要是引入市场竞争机制,同时,有效地设计规制契约与价格控制范围。卫生部门在体制与市场,以及权力结构等方面与一般公共部门具有相同特点,但在市场失灵、契约失灵等方面较为复杂,卫生部门规制的主要内容是关注医疗服务的质量、可及性和公平性。     

Insurance Status and Health Service Utilization Among Newly-Arrived Older Immigrants

Following the 1996 welfare reform, newly arrived older immigrants with less than 5 years of residence (NOIs) have been barred from Medicaid benefits. Neither are they eligible for Medicare due to lack of work history. This study examines the relationship between immigrant status (NOIs or not), health insurance, and health service use among older immigrants; whether insurance mediates the relationship between immigrant status and health service use. The 2000 National Health Interview Survey was analyzed. The sample includes respondents aged 65 or older who are foreign-born (N=1, 178). The adapted Andersen model was used. A series of logistic regressions show insurance is a complete mediator between immigrant status and health service use among older immigrants. Immigrant status was significantly related to the mediator, health insurance; older immigrants with longer than 5 years of residence were 31 times more likely than NOIs to have health insurance in terms of odds. Also, different from health service use among U.S.-born older adults, older immigrants’ service use is significantly related to their insurance status. There was no direct relationship between immigrant status and health service use.