Li Jiao, School of Labor and Personnel, Renmin University of China

Since the implementation of the new rural cooperative medical system in 2003, the research on it has never stopped, which is a hot topic at present and a creative attempt to solve the problem of farmers' medical security. Therefore, I want to make a literature review of the research in the past three years, and summarize and comment from three angles: macro-system research, commercial insurance participation in the new rural cooperative medical system research and local typical case studies.

More than 80% of the population in China live in rural areas. As a big agricultural country, farmers' medical security directly affects the social stability of rural economic development in China. Without the harmonious development of rural areas, there will be no harmonious development of the whole society. From the mid-1950s to the late 1970s and early 1980s, the government of China has been promoting the cooperative medical system in rural areas, which has played a very important role in improving the physical quality of the labor force and prolonging the average life expectancy of the rural population. In the early 1980s, due to the profound changes in the rural socio-economic structure and social system itself, the rural cooperative medical care system tended to collapse, and medical expenses became a heavy burden on rural residents, resulting in poverty and returning to poverty due to illness from time to time. In the early 1990s, the Chinese government proposed to establish and improve the new rural cooperative medical system and medical assistance system, and some places began to actively explore new forms of cooperative medical care, forming a cooperative medical model with local characteristics. At the end of 2003, the government began to pilot the new rural cooperative medical system nationwide. The new system implemented the model of taking the county as the overall planning unit and taking serious illness as the main overall planning unit.

After entering the 2 1 century, due to the sustained and rapid growth of China's economy and the rapid improvement of its comprehensive national strength, China's economic structure has entered a new development stage of "industry feeds back agriculture and cities feed back rural areas". In 2003, the central government launched a comprehensive pilot project of the new rural cooperative medical system, requiring the central and local governments to contribute per capita to the rural population in the pilot counties 10 yuan. The farmer's fund-raising is not less than 10 yuan, and the new cooperative medical fund is established according to the level of fund-raising not less than that of 30 yuan, and the pilot work is approved in 620 counties and regions, covering about 2 1% of the rural population. After more than three years of pilot, ideal results have been achieved.

Since the implementation of the system, the research on it has never stopped. It is undoubtedly of great practical significance to conduct a comprehensive and in-depth analysis and research on it from different angles and using different methods. As a creative attempt to solve the problem of farmers' medical security, the new rural cooperative medical system has aroused great concern and academic interest of sociologists as soon as it appeared. Some have studied this system from the perspective of pure theory, legislation, financing mechanism, field investigation and commercial insurance participation. Therefore, I think it is necessary to make a literature review of the research on this system in the past three years.

(a) macro-institutional research

First of all, we should compare the differences between the new rural cooperative medical insurance system and the old cooperative medical system. The key to the difference between the two is a "new" word, which is different from the old cooperative medical system implemented in the past. Zhong Jianying thinks there are five main differences:

First, the new rural cooperative medical system is a government-led medical mutual aid system for farmers, which is organized, guided and supported by the government; In the past, cooperative medical care mainly relied on rural communities to organize themselves;

Second, the source of funds for the new cooperative medical insurance mainly depends on multi-party financing invested by the government, and the central and local governments should arrange special funds to support it every year. "The specific financing ratio is:13 for the central and local governments,13 for individual farmers, and rural collective economic organizations with conditions should also give financial support; In the past, cooperative medical care funds mainly relied on individual contributions and village-level collective economic subsidies, and government finances at all levels were not responsible for financing ";

Third, the new cooperative medical insurance focuses on "serious illness as a whole", focusing on solving the problems of poverty caused by illness and returning to poverty due to illness; In the past, cooperative medical care mainly solved minor injuries and ailments, and its ability to resist risks was poor;

Fourth, the new cooperative medical insurance implements a county-based overall management system. The population of a county is more than one million in a big county and 200,000 in a small county. The scope of overall planning is large and mutual assistance is great; In the past, the cooperative medical system generally took the village as the unit (about 2000 population), and a few took the township as the unit (20,000 to 30,000 population), so the mutual assistance ability was small;

Fifth, while establishing a new cooperative medical insurance system, we should also establish a medical assistance system and set up a special fund funded by government investment and donations from all walks of life to provide medical assistance to poor families and rural "five guarantees". In addition, in economically developed rural areas, farmers are encouraged to participate in commercial medical insurance.

Many experts and scholars have pointed out the shortcomings and disadvantages of the macro-framework of the new rural cooperative medical insurance system, and put forward many suggestions and measures. I found that their common concerns are mainly in the following aspects: the reform of medical and health management system is lagging behind, and the conditions of rural medical and health services are poor; There are loopholes in the fund management of cooperative medical care; Lack of relevant legal norms; The propaganda of the new rural cooperative medical system is not enough; The government's responsibility in rural cooperative medical insurance is not clear enough. Ma also believes that the new cooperative medical care system has formed a new monopoly in a sense, leading to a false high drug price.

I don't quite agree with some views. First, some people think that most farmers have a hard life, the funds of the new rural cooperative medical system are difficult to pay, and local governments are unable to fully undertake the rescue task. I think this statement is too exaggerated. It can be seen from the system that farmers can participate in the cooperative medical system as long as each person pays 10 yuan every year. I believe that most farmers have this ability, which is not a burden to farmers at all. Second, it is difficult for farmers to understand and accept the new rural cooperative medical system. A few people are skeptical about this system and have the idea of waiting and seeing. Such a statement is simply nonsense. The cooperative medical system has been implemented for so many years, and the masses have long realized its benefits and benefits. As far as I know, even many city people who have moved to the city for many years have joined the cooperative medical system. Although there are still some imperfections in this system, it is indeed a good policy to benefit the people, which has been supported and actively participated by the majority of farmers.

In view of the shortcomings and problems of the new rural cooperative medical system, many scholars have also put forward their own suggestions and countermeasures. Strengthen the construction of legal system; Increase the propaganda of farmers; According to the different conditions in rural areas, choose the appropriate medical security model; Change the concept of growth and clarify the responsibility of the government in rural medical and health undertakings; Improve the management system of cooperative medical care and standardize the operation and supervision of cooperative medical care fund; Improve rural medical and health service conditions and actively serve farmers. Ma thinks it is necessary to introduce competition mechanism into cooperative medical care, break the medical monopoly and protect the interests of the vast majority of farmers.

In addition, there are some novel ideas. Zhao Pi and Li Xuejun believe that the dilemma of establishing a new cooperative medical system lies in multi-party game. First, the game dilemma between the central financial support for agriculture and farmers' interests; Secondly, there are three main dilemmas in the interest game between local government and central government, namely, the dilemma of "local government taking the central government's money", the dilemma of publicity and implementation of the new rural cooperative medical system, and the dilemma of whether designated hospitals become monopolies. As for how to solve this dilemma, they did not put forward substantive solutions, but only proposed some symbolic measures, such as increasing investment in rural health, strengthening health poverty alleviation and health support for agriculture, and establishing a new rural cooperative medical system.

Regarding the financing of the new rural cooperative medical system, many scholars have put forward suggestions on various financing channels. Xiao Xiangxiong and others especially mentioned the non-monetary financing methods for farmers in the west to participate in the new rural cooperative medical system: one is the new rural cooperative medical system, which is mainly based on land cooperation and supplemented by other resources; Second, the new rural cooperative medical care financing model based on labor cooperation and supplemented by other resources; Third, the new rural cooperative medical care financing method based on foreign aid; The fourth is the integration mode of the three financing methods.

(B) commercial insurance to participate in the new rural cooperative medical system research

There are two main voices about whether commercial insurance can participate in the new rural cooperative medical system. The mainstream view is that commercial insurance should be strongly encouraged to participate in the new rural cooperative medical system, while some scholars hold a negative attitude.

Wang Zaoli and others believe that the economic level of most rural areas in China, especially the central and western rural areas, is very limited. At present, the conditions for incorporating farmers' health insurance into commercial insurance are not yet mature, and it is still too early to establish farmers' medical security system by means of insurance market operation. They believe that there are three main reasons: first, the operation and reputation of insurance companies are difficult to gain the trust of farmers; Second, insurance companies lack the government's organization, guidance and support functions for the new rural cooperative medical system; Third, it is difficult for insurance companies to adapt to the particularity of the new rural cooperative medical system.

I think commercial insurance can participate in the new rural cooperative medical system, but the new rural cooperative medical system cannot be fully commercialized. People who have a negative attitude towards commercial insurance participating in the new rural cooperative medical system are conservative and lack of investigation and understanding of practice. The three main reasons they listed are not convincing. First, since the establishment of insurance companies for decades, their reputation and functions have been recognized by farmers, and more and more farmers gradually trust insurance companies and participate in insurance; Secondly, the participation of commercial insurance in the merger of new farmers does not mean the commercial insurance of the new rural cooperative medical system, and commercial insurance is participation rather than dominance. Specific ways of participation can be studied with the government.

Relevant statistics show that by the end of June, 2005, six insurance companies in China had carried out farmers' medical insurance in 68 counties (urban areas) in eight provinces (autonomous regions) such as Jiangsu and Henan, involving farmers17.65 million people, and the average participation rate in the pilot areas was 84%. Among them, 38 counties (cities, districts) were included in the pilot scope by governments at all levels, accounting for 6% of the pilot counties (cities, districts) of 64 1 new rural cooperative medical system in China. Since 2003, insurance companies have provided medical compensation services for 565,438+088,600 people.

Wei Min believes that in the past two years, the insurance industry has mainly participated in the new rural cooperative medical system in three ways. One is the fund management mode, the other is the insurance contract mode, and the third is the mixed mode. She believes that the advantages of commercial insurance participation are reflected in the following five aspects: 1. Conducive to strengthening the government's public management function; 2. It is conducive to saving government costs; 3. Conducive to controlling operational risks; 4. It is beneficial to provide more convenience for farmers! Fast service; 5. It is conducive to ensuring the safety of funds.

At the same time, Wei Min believes that there are also some problems in the development process of the insurance industry participating in the pilot project of the new rural cooperative medical system, mainly as follows: First, the difficulties and problems faced in the pilot project of the new rural cooperative medical system have become the basic reality that insurance companies must face when participating in the new rural cooperative medical system. The rural medical service infrastructure is poor, the quality of professionals is low, the rural medical assistance system is not perfect, and the medical assistance problem of the poor population can not be solved. In addition, the financing level of the new rural cooperative medical system is low and the financing cost is high. However, due to the lack of supervision of designated medical institutions, medical expenses have risen too fast. All these make insurance companies face a series of difficulties and challenges in participating in the new rural cooperative medical system. Secondly, insurance companies' participation in the new rural cooperative medical system lacks policy guidance and support, and how insurance companies participate in the new rural cooperative medical system is a new attempt and exploration. Third, insurance companies should further carefully choose and explore ways to participate in the new rural cooperative medical system, and the way to participate in the new rural cooperative medical system by insurance contract is worth exploring.

In addition, some people propose to learn from foreign models-micro-insurance organizations (hereinafter referred to as micro-insurance organizations). Zhao Liang believes that the limitations of the new medical cooperation system established by the China government in 2002 are constantly emerging. This requires us to explore the establishment of a new rural medical system to supplement the new cooperative medical system. From the practice of foreign countries, especially some developing countries, the micro-insurance organization model is worth learning. The advantages of micro-insurance organizations are: (1) reflecting social equity; Represent the interests of the demand side; Reduce operating costs; Strengthen the supervision of medical centers and improve the level of social security. As far as domestic feasibility is concerned, from foreign practical experience, micro-insurance organizations are mostly established in some areas that have just reached food and clothing, so this model is more suitable for underdeveloped poverty-stricken areas in the central and western regions. In addition, we have to pay attention to the fact that micro-insurance organizations are based on mutual trust and mutual assistance, and sufficient information among members is very necessary. In addition, the age structure of members in the organization should be relatively balanced, which objectively requires low mobility of personnel in the organization.

(C) Typical local case studies

All localities have explored the new rural cooperative medical insurance. At the same time, many places actively explore new forms of cooperative medical insurance according to the changed social, economic and political conditions. Fan believes that there are the following typical:

(1) The rural cooperative medical insurance system in Jiading District of Shanghai is handled by the township social security center (integrating rural residents' social pension, medical security and social labor employment), so that the rural cooperative medical insurance system is synchronized with the urban workers' medical insurance system. In 2002, the participation rate of farmers reached 99.49%. Fund raising adheres to the principle of "individual first, collective support and government support".

(2) The rural hospitalization medical insurance system in Jiangyin City, Jiangsu Province, which is characterized by breaking the dual structure of urban and rural areas and covering urban residents, agricultural population and migrants working in Jiangyin who have not participated in the basic medical insurance for urban workers. The funds are raised and used by the whole city, and the insured can choose their own doctors in the local and surrounding areas.

(3) The cooperative medical system in Wuxue City, Hubei Province has been going on for 48 years, which is characterized by the establishment of a farmer's cooperative medical congress system, in which farmers themselves discuss the cooperative medical scheme, review the use of cooperative medical funds, and supervise the unhealthy trends and medical ethics in cooperative medical care, which embodies the idea of letting farmers be masters of their own affairs and solves the sustainability problem of cooperative medical care.

(4) In Wangjiang County, Anhui Province, the cooperative medical care for farmers with serious illness has formed an effective supervision system: ① checks and balances of power, that is, three meetings will sign and one vote will veto-township hospitals will be the first instance, township governments will be the second instance, and county health bureaus will be the final instance, with veto power. (2) Verification procedure, that is, random sampling, one-stop (top-down)-according to the proportion of reimbursement households 10%, the county health bureau directly sends people to the village for verification; Information disclosure, posting (bottom-up)-all towns and villages publicly reimburse accounts. (3) the accountability system, that is, ten penalties for one mistake, withholding funds.

(5) Cooperative medical care in Wuxi County, Chongqing. Since 1999, the county has implemented the cooperative medical system of "combining township management with medical treatment" with the grant from the British government. In the management of funds, the principle of "earmarking, special account storage, rational use, scientific management, democratic supervision and rolling development" is followed. The funds are managed by the Rural Cooperative Medical Management Committee, deposited in credit cooperatives, managed by township financial personnel and special accounts, and supervised by the Rural Cooperative Medical Supervision Committee.

Among the collected data, the first two places have been studied the most. Zhang Liming and others have studied Jiading District of Shanghai, and think that the most obvious feature of the new rural cooperative medical insurance system in Jiading District of Shanghai is the operation mode of establishing individual account, individual paying part and regional and town-level serious illness social co-ordination, that is, each insured person is required to establish an individual account to solve the basic medical care of farmers. After reading the personal account, medical insurance will enter the personal self-payment part, which is the buffer part to control the rise of medical expenses. The cooperative medical fund can be used rationally. When it reaches a certain amount, it will enter a seriously ill society as a whole, and the reasonably adjusted funds will be used to strengthen the anti-risk efforts and alleviate and prevent poverty caused by illness. This model not only adopts the basic principles of social medical insurance, but also adopts a mechanism similar to the basic medical insurance for urban workers, and combines personal accounts with the social overall planning of serious diseases at the district and town levels, which changes the weakness of the previous cooperative medical system that small insurance does not guarantee large insurance, or the disadvantages of ensuring large insurance without small insurance. Personal accounts meet the basic medical services of farmers, and the serious illness society at the district and town levels coordinates to alleviate and prevent farmers from getting poor and returning to poverty due to illness, which provides practical experience and theoretical basis for fully entering the new cooperative medical insurance system.

Due to China's vast territory and unbalanced economic development, various localities have made new explorations and attempts on the new rural cooperative medical system according to local conditions, forming their own characteristics. But I think it is a good thing on the surface, and it may not be a good thing for the system design of the new rural cooperative medical system. First, of course, the system design is as simple and reasonable as possible, and it should not be divided into too many blocks and complicated. If the same system has its own characteristics and forms a system in different places, it is actually not conducive to the system design and coordinated development of the whole system. With the gradual narrowing of regional differences, its disadvantages will certainly hinder the further development of this system. Second, the core concept of social security is equality and justice. As citizens of the same country, the east and the west should be treated equally, instead of letting each place "have its own characteristics" and damaging the fairness of social security.