职工基本医疗保险个人账户制度的法理困境与改革重构  

The Legal Dilemma and Reform Reconstruction of the Individual Account in Basic Medical Insurance for Employees

作　　者：孙淑云 Sun Shuyun(School of Law/Social Law Research Center,Shanxi University of Finance and Economics,Taiyuan 030006,China)

机构地区：[1]山西财经大学法学院

出　　处：《社会保障评论》2024年第4期86-101,共16页Chinese Social Security Review

基　　金：国家社科基金一般项目“《医疗保障法》立法疑难问题研究”(22BFX116);教育部人文社会科学研究规划基金项目“中国多层次医疗保障法律的衔接研究”(19YJA820037)。

摘　　要：从基本医疗保险法理视角释明个人账户基金权属及其运行机制,有助于破解个人账户制度改革之认知难题。个人账户基金“建筑”在职工基本医疗保险基金之上,属法定公共基金的一部分;个人账户制度是内嵌、贯通于职工基本医疗保险全流程的重要运行制度;参保人履行缴纳保险费义务,对个人账户享有门诊、购药等待遇给付请求权。个人账户制度的建立,在促进传统医疗保障制度向社会医疗保险制度“转型”中起到了一定的积极作用。但是,带有计划经济体制的负荷性,违背基本医疗保险的社会共同责任原则、现收现付财务运行规则是其根本缺陷。改革的治本之策在于,回归基本医疗保险法理,着眼于职工基本医疗保险制度的结构性优化,对个人账户制度进行体系化改革,将个人账户基金全部纳入统筹基金,打破个人账户与统筹账户割裂异质的运行机制,重塑统筹共济保障机制,重构参保人的权利义务内容,牵引基本医疗保险制度尽快定型和法治化。Clarifying the ownership of individual account funds and their operational mechanisms from the perspective of basic medical insurance law is essential for addressing the cognitive challenges in reforming the individual account system.Individual account funds are"constructed"on the basis of employee basic medical insurance funds and are part of the statutory public funds.The individual account system is embedded in and integrated throughout the entire process of employee basic medical insurance.Insured individuals,by fulfilling their obligations to pay insurance premiums,have the right to request benefits such as outpatient services and medication from their individual accounts.The establishment of the individual account system has played a positive role in promoting the transformation of the traditional healthcare system to a social medical insurance system.However,it has inherentflaws due to its origins in the planned economic system,violating the principle of social collective responsibility in basic medical insurance and the pay-as-you-gofinancial operation rules.The fundamental approach to reform lies in returning to the legal principles of basic medical insurance.This reform should focus on structural optimization through a systematic overhaul of the individual account system.Specifically,the reform should involve incorporating all individual account funds into the pooled funds,eliminating the fragmented and heterogeneous operational mechanisms between individual and pooled accounts,reshaping the mutual aid and risk-sharing mechanism,redefining the rights and obligations of insured individuals,and guiding the basic medical insurance system towards stability and embedding it within a legal governance framework.

关 键 词：职工基本医疗保险个人账户 统筹共济保障机制 社会共同责任原则 现收现付财务运行规则 

分 类 号：R197.1[医药卫生—卫生事业管理] F842.684[医药卫生—公共卫生与预防医学]