【作者】 潘峰；

【导师】 刘宇伟； 刘玉辉；

【作者基本信息】 扬州大学 ， 农业硕士（专业学位）， 2025， 硕士

【摘要】 城乡居民基本医疗保险制度是保障公民医疗权和生命健康权的重要制度安排。自2016年《关于整合城乡居民基本医疗保险制度的意见》颁布以来,我国推动城镇居民医保与新农合整合,实现“六统一”,至2024年覆盖9.6亿余人口,参保率稳定在95%以上。然而,受地方财政能力、医疗资源分布不均、专业人才短缺等因素影响,目前城乡居民医保仍停留在市级统筹层面,各地区医保体系差异明显,制度均衡发展面临挑战。本研究选取湖南省T县作为研究对象,以社会保障理论、社会分层排斥理论和信息不对称理论为指导,采用文献研究、实地访谈和问卷调查相结合的方法,对T县城乡居民医保参保情况、基金运行和政策满意度等方面进行实证研究。研究发现:一是政策宣传与影响不到位,仅30.7%的居民对医保政策表示了解或非常了解,大部分参保居民缺乏对政策的清晰认知。二是参保意愿度降低,超过50%的居民认为现行缴费标准偏高,基层征缴工作难度加大,村级组织普遍采取代缴手段维持表面参保率。三是医疗资源分布不均,农村地区面临基本医疗保障不足,乡镇卫生院功能定位模糊,未能有效发挥分级诊疗中的承接作用。四是医保集采药品落地较差,乡镇卫生院因采购规模小面临高额物流成本,影响了农村患者用药可及性。最后是医保监管存在缺位,违规使用医保基金的现象仍无法有效遏制。针对上述问题,本研究提出以下建议:一是加强医保宣传能力建设,构建精准化、分众化宣传体系。二是优化医保缴费制度,推行收入关联缴费机制。三是完善基层医疗建设,建立基层药品供应网络,构建人才稳定轮转计划。四是优化基层集采体系,健全采购需求预测机制,建立多方协作机制。五是构建多层次医保监管体系,从监管后移转向监管前移,构建协同监管新格局。更多还原

【Abstract】 The basic medical insurance system for urban and rural residents is an important institutional arrangement to protect citizens’right to medical treatment and life and health.Since the promulgation of the Opinions on Integrating the Basic Medical Insurance System for Urban and Rural Residents in 2016,China has promoted the integration of urban residents’medical insurance and the new rural cooperative Medical care system to achieve the"six unification",covering more than 960 million people by 2024,and the participation rate has stabilized at more than 95%.However,affected by factors such as local financial capacity,uneven distribution of medical resources,and shortage of professional talents,the current medical insurance for urban and rural residents still stays at the municipal level,and the regional medical insurance systems are significantly different,and the balanced development of the system faces challenges.This study selected T County in Hunan Province as the research object,guided by social security theory,social stratification and exclusion theory and information asymmetry theory,and adopted literature research,field interviews and questionnaire survey to conduct empirical research on the medical insurance participation,fund operation and policy satisfaction of urban and rural residents in T County.The study found that:First,the policy publicity and influence were not in place,only 30.7%of residents understood or understood the medical insurance policy very well,and most of the insured residents lacked a clear understanding of the policy.Second,the willingness to participate in insurance has decreased,more than 50%of residents believe that the current payment standard is high,the grass-roots collection work is more difficult,and village organizations generally adopt the means of paying to maintain the surface participation rate.Third,the distribution of medical resources is uneven,rural areas are faced with the lack of basic medical security,the function of township health centers is fuzzy,and they fail to effectively play the role of undertaking hierarchical diagnosis and treatment.Fourth,the implementation of medical insurance collection drugs is poor,and township health centers face high logistics costs due to small procurement scale,which affects the availability of drugs for rural patients.Finally,there is a lack of medical insurance supervision,and the phenomenon of illegal use of medical insurance funds can not be effectively curbed.In response to the above problems,this study puts forward the following suggestions:First,strengthen the capacity building of medical insurance publicity,and build a precise and diversified publicity system.The second is to optimize the medical insurance payment system and implement the income-related payment mechanism.Third,improve the construction of grass-roots medical care,establish a grass-roots drug supply network,and build a stable rotation plan for talents.The fourth is to optimize the grass-roots collection system,improve the procurement demand forecasting mechanism,and establish a multi-party cooperation mechanism.The fifth is to build a multi-level medical insurance supervision system,shift from supervision to supervision forward,and build a collaborative regulatory pattern.更多还原