上海交通大学学报（医学版）

上海交通大学学报（医学版） ›› 2018, Vol. 38 ›› Issue (6): 670-.doi: 10.3969/j.issn.1674-8115.2018.06.015

• 论著·公共卫生 • 上一篇    下一篇

中国4个直辖市儿童基本医疗保险制度与政策对比研究

董媛媛 1*，张琳2*，杨颖蕾 1, 3，董伟 1，莫丹丹 1，方越 1，钱琨 1，罗梦云 1，李娜 1，张智若 1   

  1. 1.上海交通大学公共卫生学院，上海 200025; 2.民航上海医院，上海 200335; 3.上海交通大学医学院附属上海儿童医学中心，上海 200127
  • 出版日期:2018-06-28 发布日期:2018-07-03
  • 通讯作者: 李娜，电子信件：nali@sjtu.edu.cn。张智若，电子信箱：zhangzhiruo@sjtu.edu.cn。为共同通信作者。
  • 作者简介:董媛媛（1992—），女，硕士生；电子信箱：dyy714@sjtu.edu.cn。张琳（1984—），女，主治医师，硕士；电子信箱：1002596177@qq.com。*为共 同第一作者。
  • 基金资助:
    上海市加强公共卫生体系建设三年行动计划（2015—2017）（GWIV-25）

A comparative study on childrens basic medical insurance system and policies in four municipalities in China

DONG Yuan-yuan1*, ZHANG Lin2*, YANG Ying-lei1, 3, DONG Wei1, MO Dan-dan1, FANG Yue1, QIAN Kun1, LUO Meng-yun1, LI Na1, ZHANG Zhi-ruo1   

  1. 1. School of Public Health, Shanghai Jiao Tong University, Shanghai 200025, China; 2. Shanghai Hospital of Civil Aviation, Shanghai 200335, China; 3. Shanghai Children’s Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China
  • Online:2018-06-28 Published:2018-07-03
  • Supported by:
    Three Year Action Plan for Strengthening Public Health System in Shanghai,2015-2017, GWIV-25)。

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摘要： 目的·通过分析2011年和2017年上海市儿童基本医疗保险政策，并与其他3个直辖市对比，了解我国4个直辖市儿童基本医疗保障现状并分析存在的问题。方法·系统收集4个直辖市现行有效的儿童基本医疗保险政策和儿童大病保险政策及其相关保险制度。主要收集并对比各直辖市儿童基本医疗保险类型及其筹资标准、自费及政府补助比例、各级医疗机构的门急诊起付线和报销比例，以及大病保险报销比例封顶线和保障范围。结果·上海市儿童基本医疗保险为“双保险”制度，主要由城乡居民基本医疗保险和上海市中小学生、婴幼儿住院医疗互助基金构成；其他直辖市主要由城乡（镇）居民医疗保险构成。与2011年相比，2017年上海市城乡居民基本医疗保险和上海市中小学生、婴幼儿住院医疗互助基金的筹资水平及报销水平均有所提高。2017年上海市城乡居民基本医疗保险筹资水平为1 100元，略低于北京市城镇居民医保及新农合，高于天津市和重庆市的城乡居民医保筹资水平，并且上海市个人缴费水平最低；上海市住院起付线均低于其他直辖市；上海市的门急诊及住院报销水平均高于其他直辖市；上海市没有设置封顶线，而其他直辖市均设有封顶线；各直辖市大病保障政策差异较大。结论·各直辖市根据各自的实际情况，因地制宜建立了与其社会经济发展相适应的儿童医疗保障模式。上海市儿童基本医疗保险基本满足儿童成长的需求，在大病保障的种类及保障水平方面尚需完善。

关键词: 儿童, 医疗保险, 对比研究

Abstract:

Objective · To analyze the basic medical insurance policies for children in Shanghai in 2011 and 2017, and compare with those of the other three municipalities to understand the basic medical security status of children in four municipalities in China and analyze the existing problems. Methods · The current effective childrens basic medical insurance policies and child critical illness insurance policies and related insurance systems in four municipalities were collected systematically. The types of basic medical insurance for children in various municipalities and their funding standards, their own expenses and the proportion of government subsidies, the proportion of outpatient emergency payoff lines and reimbursement at all levels of medical institutions, and the coverage and coverage of major illness insurance reimbursement were collected and compared mainly. Results · The basic medical insurance for children in Shanghai is a “double insurance” system, which contained childrens hospitalization fund and basic medical insurance for urban and rural residents. The basic medical insurance for children in other municipalities mainly consisted of basic medical insurance for urban (rural)residents. Compared with 2011, the level of financing and the reimbursement of the basic medical insurance for urban and rural residents and of the childrens hospitalization fund in Shanghai in 2017 was increased. In 2017, the level of financing of basic medical insurance for urban and rural residents in Shanghai was 1 100 yuan, which was slightly lower than that of Beijing medical insurance for urban residents and new rural cooperative medical insurance and was higher than that of basic medical insurance for urban and rural residents in Tianjin and Chongqing, and the individual payment level of Shanghai was the lowest. The hospitalization payoff lines in Shanghai were lower than those of other municipalities. Shanghais outpatient and inpatient reimbursement levels were higher those of than other municipalities. There wasnt a capping line in Shanghai. There were capping lines in other municipalities. There was a great difference in the insurance policy of the major diseases in four municipalities. Conclusion · According to their own actual conditions, models for childrens medical care systems that suited each municipalities’ social and economic development have been established. Shanghai childrens basic medical insurance basically meets the needs of childrens growth but needs improvement in terms of the type and level of medical security for major illnesses.

Key words: children, medical insurance, comparative study

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