CAJ | 학술논문

基于医疗保障城乡一体化改革，湛江的大病医疗保障采取商业保险与社会保险结合的模式，通过商业健康保险机构与政府部门合作运营管理大病医疗保障，显著降低了城乡居民发生灾难性医疗支出的比例；其发挥市场机制为城乡居民提供医疗保障的政策理念和政府与商业保险机构分工协作、共担风险、共同运营管理的经验做法，具有普遍借鉴意义。大病医疗保障“湛江模式”也存在“一刀切”式的经济补偿标准有悖公平、“保重大疾病、保高额住院医疗费”的重点未能反映“大病风险”的本质以及缴费水平的差距不大、商业健康保险机构参与深度和广度不够等不足。大病医疗保障是“特惠型”的保障制度，保障水平需要与经济社会发展水平相适应，应全面考量大病风险损失，分类评估家庭大病风险承受能力，充分发挥商业健康保险机构的大病风险管理职能，并根据大病风险损失的严重程度实施差异化补偿标准，避免家庭发生灾难性医疗支出。
기우의료보장성향일체화개혁，담강적대병의료보장채취상업보험여사회보험결합적모식，통과상업건강보험궤구여정부부문합작운영관리대병의료보장，현저강저료성향거민발생재난성의료지출적비례；기발휘시장궤제위성향거민제공의료보장적정책이념화정부여상업보험궤구분공협작、공담풍험、공동운영관리적경험주법，구유보편차감의의。대병의료보장“담강모식”야존재“일도절”식적경제보상표준유패공평、“보중대질병、보고액주원의료비”적중점미능반영“대병풍험”적본질이급격비수평적차거불대、상업건강보험궤구삼여심도화엄도불구등불족。대병의료보장시“특혜형”적보장제도，보장수평수요여경제사회발전수평상괄응，응전면고량대병풍험손실，분류평고가정대병풍험승수능력，충분발휘상업건강보험궤구적대병풍험관리직능，병근거대병풍험손실적엄중정도실시차이화보상표준，피면가정발생재난성의료지출。
Based on urban and rural integrated medical insurance reform, the medical insurance of Zhanjiang for a serious disease uses the model by combining commercial insurance and social security, manages the medical insurance for a serious disease via the cooperation between commercial healthy insurance agencies and governmental departments, significantly decreases the proportion of “disastrous medical expenditure” in urban and rural residents, which is of ubiquitous reference significance by playing a role in mutual management and mutually taking the risk as well as the division of labor between the governments and commercial insurance agencies via letting the policies and ideas of market mechanism provide the medical insurance for urban and rural residents. The “single-type” economic compensation standard of“Zhanjiang Model” for a serious disease in medical insurance is paradox to the fairness, and the principle for “the medical insurance for serious diseases and high cost in hospitalized payment” does not reflect the essence of “the risk of serious diseases”, small medical cost gap and insufficient participation degree and extension of commercial insurance agencies. The medical insurance for a serious disease is“special beneficial type” insurance system, its insurance level should befit the economic and social development level, overall consider the risk and loss for a serious disease, evaluate in classification the bearing ability for a serious disease of a family, bring the management duty of commercial insurance agencies for a serious disease into fully play, and implement different compensation standards according to the serious degree of the risk and loss for a serious disease in order to avoid “disastrous medical expenditure” for a family.