美国医疗保险制度的演变逻辑——基于历史制度主义的分析  

The Evolutionary Logic of the U.S.Health Insurance System:An Analysis from the Historical Institutionalism Perspective

作　　者：胡文秀 徐成 Hu Wenxiu;Xu Cheng(Center for Population and Development Policy Studies,Fudan University,Shanghai;School of Government,East China University of Political Science and Law,Shanghai)

机构地区：[1]复旦大学人口与发展政策研究中心 [2]华东政法大学政府管理学院

出　　处：《经济社会体制比较》2023年第5期188-197,共10页Comparative Economic & Social Systems

基　　金：国家留学基金委国家建设高水平大学公派研究生项目(项目编号:201806360115)。

摘　　要：美国是世界上唯一一个没有建立全民公共医保的发达国家,而是形成了一种私人医保为主、公共医保为辅的混合型医疗保障制度。在新冠疫情的冲击下,美国医疗保障制度的弊端日益凸显。文章从历史制度主义的视角出发,研究美国医保制度的发展演变。文章指出,在美国公共医保建立前,私人医保的发展在很大程度上决定了美国医保制度的发展方向。文章认为,20世纪30年代的罗斯福新政构成了美国医保制度发展史上限制与机遇并存的关键节点,罗斯福政府出于利益集团阻碍等结构性制约和改革优先事项考虑,没有充分发挥其在医保问题上的能动性,做出了放弃公共医保的妥协选择,致使私人医保借此窗口期迅速发展起来,并在路径依赖效应下逐步成为美国医保制度的核心,此后发展起来的公共医保只能是对私人医保的补充、完善,而无法取代其核心地位,由此形成了混合型医保制度。厘清美国医保制度的发展变迁,对中国当前的医疗保障制度改革也具有重要启示。The United States stands out among developed nations for not having established universal public health insurance,instead adopting a mixed medical security system led by private insurance and supplemented by public coverage.The vulnerabilities of the U.S.healthcare system have been increasingly evident,particularly under the impact of the COVID-19 pandemic.This paper explores the evolution of the U.S health insurance system from the lens of historical institutionalism.The study highlights that the extent of private health insurance development prior to the establishment of public health insurance played a significant role in shaping the trajectory of the U.S.health insurance system.The paper argues that the New Deal implemented during Roosevel's administration in the 1930s marked a crucial turning point in the development of the U.S.health insurance system.The New Deal presented both constraints and opportunities for reform.However,due to various structural constraints such as resistance from interest groups and considerations of reform priorities,the Roosevelt administration did not fully exploit its capacity to address health insurance issues,ultimately choosing to abandon public health insurance.This decision paved the way for the rapid growth of private health insurance during that period.As a result of path dependency,private health insurance gradually became the cornerstone of the U.S.health insurance system.Subsequently developed public health insurance programs could only serve as supplements and refinements to the private health insurance system,rather than replacing its central role.This led to the formation of a hybrid health insurance system.A comprehensive understanding of the development and transition of the U.S.health insurance system offers valuable insights for ongoing reforms in China's medical insurance system.

关 键 词：医疗保险 历史制度主义 关键节点 路径依赖 罗斯福新政 

分 类 号：R199[医药卫生—卫生事业管理]