The Prices in the Crises: What We Are Learning from 20 Years of Health Insurance in Low- and Middle-Income Countries
中文摘要
许多中低收入国家的政府正在开发医疗保险产品，以此补充由税收资助、通过公立医疗机构提供的补贴性医疗服务。我们讨论了这一转变的两个理由。第一，医疗保险有望增加用于医疗卫生的财政收入，因为患者在治疗后向医疗服务提供者支付的自付费用，将由其在治疗前向卫生部门缴纳的保险费所取代。第二，扩大患者的选择权并精心设计医生报销机制，有望提高医疗卫生部门的服务质量。本文表明，这些目标即使有所实现，至多也只是部分实现。尽管有证据显示医疗保险提供了财务保障，但消费者并不愿意支付未获补贴的保险费。尽管医疗服务利用率有所提高，健康结果却没有改善。我们认为，这并不是因为医疗服务质量不存在改善空间，而是因为医疗服务提供者的行为反应系统性地削弱了这些保险计划的目标。
Abstract
Governments in many low- and middle-income countries are developing health insurance products as a complement to tax-funded, subsidized provision of healthcare through publicly-operated facilities. We discuss two rationales for this transition. First, health insurance would boost fiscal revenues for healthcare, as post-treatment out-of-pocket payments to providers would be replaced by pre-treatment insurance premia to health ministries. Second, increased patient choice and carefully designed physician reimbursements would increase quality in the healthcare sector. Our essay shows that, at best, these objectives have only been partially met. Despite evidence that health insurance has provided financial protection, consumers are not willing to pay for unsubsidized premia. Health outcomes have not improved despite an increase in utilization. We argue that this is not because there was no room to improve the quality of care but because behavioral responses among healthcare providers have systematically undermined the objectives of these insurance schemes.