中國醫療保障代際公平的實現策略: 論基於“愛有差等”的儒家家庭醫療儲蓄帳戶

Inter-Generational Equity in Healthcare: Family Savings Accounts Based on the Confucian Idea of “Love with Distinction”

Abstract

LANGUAGE NOTE | Document text in Chinese; abstract also in English.

不同於發達國家以及其他發展中國家，中國大陸的人口老齡化及其趨勢有著自己獨特的背景：一方面是在實施人口控制政策的過程中形成的，另一方面具有“未富先老”的顯著特徵。這樣，中國的人口老齡化就帶來了“代際公平”的嚴重挑戰：人們如果不在年輕時期為自己年老的時期儲蓄和積累必要的財富，就從一定意義上構成了對現時年輕一代的不公平：年輕一代為此要為年老一代付出過多的負擔和責任！但令人遺憾的是，中國大陸目前的醫療保健制度設計並沒有充分考慮到“代際公平”問題。因為考慮代際公平的醫療保障制度設計，至少應該以“家庭”為本位和含有“儲蓄”元素。為此，筆者提出“家庭醫療儲蓄帳戶”的設想，認為家庭醫療儲蓄帳戶有利於實現醫療保障的代際公平，即縱向公平。家庭醫療儲蓄帳戶的儒家倫理基礎符合儒家的“仁者愛人”價值，符合儒家的“愛有差等”的家庭價值觀。

Healthcare resource allocation, which has medical, ethical, and economic dimensions, has sparked recent controversy China. However, neither the concept of equality nor the concept of rights addresses the real problem of healthcare allocation that China is facing as its aging population increases. Given the real crises of the growing elderly population and the increased demands on the limited resources of the healthcare system, the author contends that a Confucian model that favors family management in the form of family savings accounts is more a feasible method for China than state management. Moreover, the family savings account model represents traditional Confucian family values and the Confucian concept of “love with distinction.”

The argument in support of the family savings account model is reinforced by the problem of the aging population and the idea of “inter-generation equity.” From an investment perspective, inter-generational equity follows the principle that an endowed institution’s spending rate must not exceed its after-inflation rate of compound return, so that investment gains are spent equally on the current and future constituents of the endowed assets. This idea also works well with the family-oriented health savings accounts, because the family as “a saving institution” is accountable for safeguarding against the unnecessary medical spending that often occurs when the money belongs to a public account or when savings are not allowed to be passed along to the next generation.

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