《保险研究》20220101-《“惠民保”发展模式研究》（《“惠民保”发展模式研究》课题组）

［摘   要］“惠民保”是在“政府指导、市场运作”逻辑下商业健康保险的一次产品创新和模式变革，是政府推进多层次医疗保障体系建设的一次重要尝试。本文对比分析基本医保、大病医保、百万医疗产品，认为坚持“普惠性”方向，围绕“价值性”与“可持续性”平衡机制，“惠民保”能紧密衔接基本医保，并实现保障结构的优化；梳理美国、新加坡案例，认为坚持普惠与有偿相结合可以促进供需循环，通过产品形态与规则的科学界定能确保交易公平性，通过专业与精细化管理赋能能实现可持续经营，应对参保率不足与死亡螺旋问题。中国“惠民保”模式开创了自己的特色道路，坚持走普惠型政企合作模式，形成更广泛的共保模式，以实现保险风控与普惠的平衡，使得主体职能边界日趋清晰，产品供给在区域整合中优胜劣汰。建议从顶层设计上坚定其“普惠”属性，从运营管理上提升多层次保障供给水平，丰富健康服务供给，拓宽健康生态合作，维系可持续健康发展道路。

［关键词］惠民保；普惠保险；死亡螺旋；普惠型政企合作模式

［作者简介］执笔人：金小桃，原国家卫生和计划生育委员会副主任、党组成员，现任中国卫生信息与健康医疗大数据学会会长；王琴，中国卫生信息与健康医疗大数据学会健康保险工作委员会秘书长；陈诗雨，中国卫生信息与健康医疗大数据学会健康保险工作委员会办公室主任；王起国，国务院发展研究中心副研究员、中国发展研究基金会项目主任；戚开铭，太平洋健康险科创办主任；谢远涛(通讯作者)，对外经济贸易大学保险学院教授、副院长(主持工作)、博士生导师，研究方向:精算学。

A Research on the Development Model of “City-customized Medical Insurance”

The Research Group for the Development Model of “City-customized Medical Insurance”

Abstract：The “City-customized Medical Insurance” is a product innovation and development model transformation for commercial health insurance following the logic of government guidance and market orientation,and an important experiment for the government in promoting the construction of a multi-tier medical security system.The paper compared the basic social medical insurance plan,the complementary major medical expenses insurance,and the commercial million-yuan medical insurance.It held the opinion that sticking to its “inclusiveness”,and balancing “value” and “sustainability”,the “City-customized Medical Insurance” can coordinate well with the basic social medical insurance plan and optimize the overall protection structure.A review on relevant American and Singapore cases shows that the combination of inclusive and non-gratuitous insurance can promote smooth supply-demand circulation.Fine definition of product forms and rules can ensure the fairness of transactions;specialized and intensive management can help with sustainable operation,addressing the issues of insufficient participation and death spiral.China′s “City-customized Medical Insurance” model has opened up a new route.We should stick to the government-enterprise cooperation model in inclusive insurance and form a broader co-insurance business model in order to achieve the equilibrium between insurance risk control and inclusiveness.Moreover,the role of various participants has been gradually defined and good products survive in regional consolidation.The paper suggested to strengthen its “inclusiveness” in top-level design,enhance multi-level protection supply in operation,enrich the supply of health services,broaden the cooperation among various health ecologies,thus maintain its sound and sustainable development.

Key words：City-customized Medical Insurance;death spiral;inclusive government-enterprise cooperation model