（原編者按：深化公立醫(yī)院改革，首先要有正確的理論指導(dǎo)。當(dāng)前，一些觀點(diǎn)用過(guò)于簡(jiǎn)單的競(jìng)爭(zhēng)性市場(chǎng)一般均衡模型解釋公立醫(yī)院改革，得出似是而非的結(jié)論。

　　20世紀(jì)60年代以來(lái)，西方經(jīng)濟(jì)學(xué)也發(fā)生了深刻變化。以信息經(jīng)濟(jì)學(xué)、契約理論和機(jī)制設(shè)計(jì)為主要代表，過(guò)去的市場(chǎng)-政府二分法已經(jīng)被大大超越。但是，由于這些方法尚未被我國(guó)大多數(shù)學(xué)者所熟悉，從而制約了對(duì)公立醫(yī)院的認(rèn)識(shí)。

　　本文是許定波教授針對(duì)一位經(jīng)濟(jì)學(xué)研究者“經(jīng)濟(jì)學(xué)教科書(shū)中沒(méi)有公益性概念”的謬論所寫(xiě)的文章。深入淺出地用現(xiàn)代經(jīng)濟(jì)學(xué)的理論講述了如何理解公立醫(yī)院。

　　本文原文由許教授用英文撰寫(xiě)，原題為“On the Great Debate on Reforming China’sHealth Care System-- Some possibly biased “objective” comments”，中文版由國(guó)務(wù)院發(fā)展研究中心江宇翻譯）

　　正文

　　圍繞中國(guó)醫(yī)改方向的大辯論，已經(jīng)持續(xù)多年，今年4月，中國(guó)政府正式明確了“政府主導(dǎo)”的醫(yī)改方向。但是，關(guān)于醫(yī)改的辯論并未偃旗息鼓，反而出現(xiàn)了更濃的火藥味。一方面，廣大公眾感到歡欣鼓舞，另一方面，經(jīng)濟(jì)學(xué)家卻進(jìn)一步分化成觀點(diǎn)針?shù)h相對(duì)的陣營(yíng)。許多局外人被搞糊涂了——經(jīng)濟(jì)學(xué)家的分歧到底在哪里?

　　對(duì)于那些反對(duì)“政府主導(dǎo)”的人，我十分贊賞他們的信仰堅(jiān)定，不管現(xiàn)實(shí)世界如何變化，他們始終堅(jiān)持自己的觀點(diǎn)，堅(jiān)貞不渝。他們對(duì)市場(chǎng)充滿信任，而對(duì)政府充滿擔(dān)心，擔(dān)心政府配置資源效率不高，擔(dān)心政府主導(dǎo)的醫(yī)改會(huì)像其他福利項(xiàng)目那樣帶來(lái)過(guò)高的成本。他們認(rèn)為，對(duì)待政府就要像弗里德曼(Milton Friedman)提出的“困獸(starving the beast)”那樣，限制政府配置資源的權(quán)力，因?yàn)檎畷?huì)把自己掌握的一切資源都花掉或者浪費(fèi)掉，弗里德曼的這個(gè)理論，在世界各地的學(xué)者和公眾當(dāng)中，都有大批的支持者，中國(guó)那些支持市場(chǎng)主導(dǎo)醫(yī)改的經(jīng)濟(jì)學(xué)家，無(wú)疑對(duì)此也是認(rèn)同的。

　　然而，和德高望重的弗里德曼他老人家相比，中國(guó)一些支持市場(chǎng)主導(dǎo)醫(yī)改的經(jīng)濟(jì)學(xué)家實(shí)在讓人大失所望。他們雖然在討論中也不斷提到經(jīng)濟(jì)學(xué)概念和理論，但給我們的感覺(jué)是，許多人對(duì)當(dāng)代經(jīng)濟(jì)學(xué)的最新進(jìn)展一片茫然，誠(chéng)所謂“不知有漢，無(wú)論魏晉”也。因?yàn)檎莆盏姆治鍪侄斡邢蓿运麄儾荒軌虺浞掷斫忉t(yī)療衛(wèi)生的特性，反而把他們自己沒(méi)聽(tīng)說(shuō)過(guò)的——比如“醫(yī)療衛(wèi)生的公益性”，當(dāng)成是“錯(cuò)誤的經(jīng)濟(jì)學(xué)理論”。一些經(jīng)濟(jì)學(xué)家在討論中喜歡使用花哨的概念，故作神秘和高深，但是卻不愿意花時(shí)間搞清楚，醫(yī)療衛(wèi)生的真正特性是什么。

　　我這篇文章要說(shuō)的是，醫(yī)療衛(wèi)生和其他領(lǐng)域有哪些本質(zhì)區(qū)別?我會(huì)介紹現(xiàn)代經(jīng)濟(jì)學(xué)中對(duì)理解醫(yī)療衛(wèi)生問(wèn)題十分重要的一個(gè)分支，以此來(lái)說(shuō)明，那種認(rèn)為政府主導(dǎo)就是和現(xiàn)代經(jīng)濟(jì)學(xué)矛盾的觀點(diǎn)，恰恰是對(duì)現(xiàn)代經(jīng)濟(jì)學(xué)不了解造成的。現(xiàn)代經(jīng)濟(jì)學(xué)與市場(chǎng)和政府主導(dǎo)都不矛盾。社會(huì)最終選擇政府還是市場(chǎng)，取決于這個(gè)社會(huì)要實(shí)現(xiàn)什么樣的目標(biāo)。

　　過(guò)去半個(gè)世紀(jì)，經(jīng)濟(jì)理論最偉大的進(jìn)展是信息經(jīng)濟(jì)學(xué)(又叫代理理論)，幾代經(jīng)濟(jì)學(xué)家把畢生精力用于信息經(jīng)濟(jì)學(xué)的研究，Leo Hurwicz、Roger B. Myerson、Eric S.Maskin作為其中的杰出代表，相繼獲得諾獎(jiǎng)。信息經(jīng)濟(jì)學(xué)有助于理解中國(guó)和其他國(guó)家關(guān)于醫(yī)療衛(wèi)生體制的爭(zhēng)論。

　　我們討論的起點(diǎn)是：醫(yī)療衛(wèi)生和制造業(yè)、服務(wù)業(yè)等其他行業(yè)有一個(gè)根本區(qū)別：醫(yī)療衛(wèi)生需要風(fēng)險(xiǎn)分擔(dān)（risk sharing)。醫(yī)療服務(wù)是由疾病帶來(lái)的需求，而疾病并不是平均發(fā)生在每個(gè)人身上，與人的收入也沒(méi)有必然聯(lián)系，在飲食業(yè)，可以富人吃燕窩，窮人吃米飯，但是窮人和富人都有可能得大病。

　　風(fēng)險(xiǎn)分擔(dān)最傳統(tǒng)的方式是建立一個(gè)一體化的保險(xiǎn)市場(chǎng)，所有潛在的患者都參加保險(xiǎn)。但是，保險(xiǎn)機(jī)制要充分發(fā)揮作用，需要一個(gè)前提，即在參加保險(xiǎn)的時(shí)候，人和人之間是同質(zhì)的。不幸的是，現(xiàn)實(shí)并不那么簡(jiǎn)單：按照收入高低，社會(huì)分為不同的收入階層。盡管一些市場(chǎng)原教旨主義者不同意，但是絕大多數(shù)生活在現(xiàn)代文明社會(huì)中的人都承認(rèn)，即使最弱勢(shì)的群體也應(yīng)該享有基本的醫(yī)療服務(wù)。

　　因此，盡管醫(yī)療體系和傳統(tǒng)的保險(xiǎn)都具有風(fēng)險(xiǎn)分散的功能，但是除此之外，醫(yī)療體系還具有福利功能。一個(gè)社會(huì)必須通過(guò)直接或者間接的方式，保證所全體民眾都能享有一定水平的醫(yī)療服務(wù)。

　　如果所有人在參加保險(xiǎn)前是同質(zhì)的(疾病風(fēng)險(xiǎn)和收入都相同)，那么一個(gè)良好的保險(xiǎn)體系的效率不會(huì)比政府主導(dǎo)醫(yī)療服務(wù)來(lái)得差。保險(xiǎn)體系是一個(gè)三方博弈：患者、醫(yī)療服務(wù)提供方、保險(xiǎn)方(如商業(yè)保險(xiǎn)公司)。信息經(jīng)濟(jì)學(xué)告訴我們，醫(yī)療服務(wù)提供者的利潤(rùn)等于社會(huì)保留利潤(rùn)率（reserved profit）加上信息租金（informational rent)，其中信息租金隨著醫(yī)療服務(wù)方和付費(fèi)方之間信息不對(duì)稱(chēng)的程度而增加。所以，一個(gè)好的保險(xiǎn)制度應(yīng)該是這樣的：醫(yī)療服務(wù)提供者有動(dòng)力控制成本;保險(xiǎn)者有動(dòng)力降低信息不對(duì)稱(chēng)的程度。如果制度設(shè)計(jì)合理，這是可以達(dá)到的(美國(guó)的HMOs是一個(gè)例子)。

　　但是，前面說(shuō)過(guò)，醫(yī)療保險(xiǎn)還有福利功能，政府必須保證所有居民都能享受不低于一定水平的醫(yī)療服務(wù)。這個(gè)要求就可以叫做醫(yī)療衛(wèi)生的“公益性”，這和外部性、自然壟斷等是不一樣的。公益性的要求，從本質(zhì)上改變了博弈的規(guī)則。如果我們?nèi)匀徊扇∫粋€(gè)保險(xiǎn)體系，博弈就變?yōu)樗姆讲┺模夯颊摺⒎?wù)提供者、保險(xiǎn)者、政府。其中，患者承擔(dān)部分醫(yī)療成本，剩下的政府承擔(dān)。這個(gè)體系會(huì)出現(xiàn)一個(gè)可怕的問(wèn)題：因?yàn)檎档祝员ｋU(xiǎn)者和政府之間也存在著信息不對(duì)稱(chēng)，保險(xiǎn)者也有了信息租金，同時(shí)卻失去了控制信息不對(duì)稱(chēng)的動(dòng)力。結(jié)果就是急劇上升的成本。

　　那么，既然政府的介入導(dǎo)致成本上升，這是不是否定政府主導(dǎo)的理由呢?不是。因?yàn)楸ＷC人人享有基本醫(yī)療服務(wù)是政府不可推卸的職能。政府履行這一公益性職能，三方博弈變成四方博弈，導(dǎo)致成本上升。解決這個(gè)問(wèn)題的辦法是，讓政府同時(shí)承擔(dān)出資者和保險(xiǎn)者的職能。

　　讓政府同時(shí)承擔(dān)出資者和保險(xiǎn)者的職能，又有兩種途徑。一是政府舉辦社會(huì)醫(yī)療保險(xiǎn)，由市場(chǎng)提供醫(yī)療服務(wù)(市場(chǎng)提供);二是政府直接舉辦和提供服務(wù)(政府提供)。社會(huì)必須要在這兩種途徑中選擇一種占主導(dǎo)地位，騎墻是不行的。最壞的制度，就是兩種途徑的混合：市場(chǎng)把最肥的那部分蛋糕(收入高、疾病風(fēng)險(xiǎn)低的人群)挑選出來(lái)，賺取利潤(rùn);而政府不得不為最窮、最病的那部分人承擔(dān)責(zé)任。對(duì)于食品、住房這種不存在風(fēng)險(xiǎn)分擔(dān)的產(chǎn)品，高端和低端之間的市場(chǎng)分層是起作用的，政府只管窮人是可以的。但是，在醫(yī)療領(lǐng)域這么做，就完全破壞了風(fēng)險(xiǎn)分擔(dān)的機(jī)制。

　　既然不能騎墻，就讓我們比較一下這兩種途徑的優(yōu)劣。

　　先說(shuō)市場(chǎng)提供。市場(chǎng)提供的途徑，存在三方博弈中存在的逆向選擇和道德風(fēng)險(xiǎn)的問(wèn)題。而其優(yōu)勢(shì)在于：(1)競(jìng)爭(zhēng)能夠促進(jìn)醫(yī)院提高運(yùn)行效率(但是，運(yùn)行效率提高未必意味著降低患者的成本);(2)競(jìng)爭(zhēng)能夠促進(jìn)技術(shù)創(chuàng)新;(3)提高了服務(wù)的多樣性;(4)競(jìng)爭(zhēng)提高服務(wù)質(zhì)量。那么，逆向選擇和道德風(fēng)險(xiǎn)的問(wèn)題能否解決?市場(chǎng)主導(dǎo)論的支持者始終不渝地相信，通過(guò)競(jìng)爭(zhēng)和政府監(jiān)管能夠降低信息不對(duì)稱(chēng)的程度(盡管只有不太市場(chǎng)原教旨主義的經(jīng)濟(jì)學(xué)家才接受政府監(jiān)管)。

　　再說(shuō)政府提供。代理理論表明，政府提供最有吸引力的特點(diǎn)是，把原來(lái)的三方博弈變成了兩方博弈。政府既是支付者，又是醫(yī)療服務(wù)的提供者。政府同時(shí)承擔(dān)這兩個(gè)角色，解決了道德風(fēng)險(xiǎn)和逆向選擇的問(wèn)題，三方變成兩方之后，原來(lái)存在于付費(fèi)者和服務(wù)提供者之間的信息不對(duì)稱(chēng)問(wèn)題就不存在了，把付費(fèi)者和服務(wù)提供者之間的交易成本內(nèi)部化了。這種體系還很好地解決了長(zhǎng)期困擾許多國(guó)家的教學(xué)醫(yī)院撥款和培育優(yōu)秀醫(yī)生的問(wèn)題，教學(xué)醫(yī)院和醫(yī)療人才培育是具有傳統(tǒng)的公共品特性的。一個(gè)完整的國(guó)家醫(yī)療服務(wù)體系，還可以很好地發(fā)揮現(xiàn)代醫(yī)學(xué)的規(guī)模效益和信息技術(shù)的優(yōu)勢(shì)，在系統(tǒng)內(nèi)部促進(jìn)信息收集和共享，大幅度提高微觀管理的績(jī)效。

　　市場(chǎng)提供的四個(gè)長(zhǎng)處，相應(yīng)地是政府主導(dǎo)體系的短處。除此之外，政府主導(dǎo)體系還有一個(gè)潛在的問(wèn)題：政府是納稅人的代理人，需要通過(guò)強(qiáng)有力而精細(xì)的監(jiān)督，才能保障政策目標(biāo)在現(xiàn)實(shí)中得到貫徹。這需要對(duì)整個(gè)醫(yī)療衛(wèi)生系統(tǒng)建立一個(gè)績(jī)效考核系統(tǒng)，徹底告別傳統(tǒng)的以營(yíng)利為目標(biāo)的考核辦法，真正把健康績(jī)效的提高作為考核的激勵(lì)。

　　很明顯，現(xiàn)代信息經(jīng)濟(jì)學(xué)不僅與政府主導(dǎo)和市場(chǎng)主導(dǎo)都不矛盾，而且可以幫助我們深入了解兩種體系的優(yōu)勢(shì)和劣勢(shì)，國(guó)際上用信息經(jīng)濟(jì)學(xué)研究醫(yī)療衛(wèi)生的文獻(xiàn)也越來(lái)越多。但奇怪的是，對(duì)于理解醫(yī)療衛(wèi)生如此重要的一個(gè)經(jīng)濟(jì)學(xué)分支，在中國(guó)醫(yī)改的大辯論中卻很少有人提到。在市場(chǎng)主導(dǎo)派的陣營(yíng)，有一些經(jīng)濟(jì)學(xué)家似乎學(xué)過(guò)一些信息經(jīng)濟(jì)學(xué)，但是大部分人完全不了解這個(gè)經(jīng)濟(jì)學(xué)的前沿領(lǐng)域。

　　原因在哪里?我可以設(shè)想一些原因：(1)意識(shí)形態(tài)上根深蒂固的偏見(jiàn)，使他們對(duì)理論的新進(jìn)展視而不見(jiàn);(2)他們的能力有限，不足以理解甚至了解這一新領(lǐng)域，信息經(jīng)濟(jì)學(xué)要求熟練的數(shù)理基礎(chǔ)。悲哀的是，許多介入醫(yī)改討論的“著名經(jīng)濟(jì)學(xué)家”，實(shí)際上對(duì)現(xiàn)代經(jīng)濟(jì)學(xué)前沿一無(wú)所知，還假裝他們懂得一切。需要強(qiáng)調(diào)的是，我并非先入為主地支持任何一種觀點(diǎn)，我只是提供一個(gè)分析框架，并且指出，任何討論都需要克服偏見(jiàn)和知識(shí)面的局限性。

　　總結(jié)一下，在辯論中指責(zé)任何概念，都不是聰明的辦法。對(duì)于醫(yī)改的道路這樣一個(gè)重大問(wèn)題的抉擇，需要從偏見(jiàn)和意識(shí)形態(tài)中走出來(lái)，需要對(duì)歷史上試驗(yàn)過(guò)和現(xiàn)實(shí)中存在的不同制度進(jìn)行深入、細(xì)致、誠(chéng)實(shí)和不帶偏見(jiàn)的實(shí)證研究。

　　On the Great Debate on Reforming China’sHealth Care System

　　-- Some possibly biased “objective”comments

　　Dingbo Xu

　　Professor of Accounting

　　China Europe International BusinessSchool

　　June 21, 2009

　　Preliminary Draft

　　The debate regarding China’s health caresystem reform has been going on for many years and has become more divisive andemotional since the government announced its blueprint which favors thegovernment-led approach. While the general public appears to be fairlyenthusiastic about this approach, economists are divided into groups withfiercely different opinions. Their debate has confused many people outside ofthe professional economist circle.

　　I am sympathetic to those who oppose thegovernment-led approach because of their ideological conviction. They favorusing market forces to allocate resources and have fundamental suspicionstowards the efficiency level of government allocation mechanisms. Some alsoworry about the tendency of ever-expanding coverage and the resulting highcosts associated with many government-run social welfare programs. MiltonFriedman’s idea of “starving the beast [1]”has found a lot of receptive audiences in many corners of the world and he, asan economist, is widely respected by economists as well as many in the generalpublic. However, when those Chinese economists who support the market approachstarted to use economic concepts and theories in their discussion, many of themchose to ignore useful main-stream findings in economic theory and practice.Some are trying to make this discussion a debate of concepts, which may appearpowerful and mysterious to the general public. But these twisted concepts andtheories often miss the real nature of the health care sector.

　　Let me cite two influential groups here.One group refuses to recognize any special differences between the health caresector and other sectors. They even used the restaurant industry as proof ofmarket efficiency to justify their opposition to the government-led approach.Some other economists support government intervention, but only whenexternalities and natural monopolies are involved. They even question the veryvalidity of the concept of “公益性 [2] ”.

　　In this essay, I will discuss a fewfundamental differences between the health care sector and other sectors andintroduce a branch of modern economic research that is vital to understandinghealth care issues. I will show that modern economics does not contradicteither the market or the government-led approach. The final choice depends on asociety’s collective value preference and on careful and objective empiricalstudies of real practices.

　　The greatest discovery in economic theoryin the past half a century is in the field of information economics (often alsocalled agency theory). Leo Hurwicz，Myerson, Maskin, and several generationsof economists have devoted their entire lives into the development of thistheory. Several of them have been awarded with the Nobel economics prize fortheir contributions. This theory can shed light into the current health caredebate in China and in other countries.

　　There is an important characteristicseparating the health care industry from other industries such as themanufacturing or service industries – that is risk sharing. Sickness does notoccur to all people at the same time and does not occur in proportion to aperson’s wealth.

　　A popular and time-tested method to dealwith the risk sharing problem is to build up a comprehensive insurance market.However, there is an implicit assumption underlying this insurance approach. Itis that people are homogenous ex ante to their participation in the insurancemarket.

　　However, in reality, there is one smallinconvenience: people are divided into different wealth groups. Even thoughsome market fundamentalists may disagree, most people living in a civilizedsociety probably agree that even the most disadvantage group of citizensdeserves a basic level of health care.

　　That leads to another important featurethat separates the health care system from a traditional insurance system: thewelfare function. A society must provide resources, money or hospital services,directly or indirectly, to ensure a certain level of health service to allcitizens.

　　When people are homogenous ex ante (interms of wealth and the likelihood of becoming sick), a good insurance marketprobably will perform no less efficiently than a system directly provided bythe government. In the game, we have three parties: patients, the health careservice provider, and the insurer. Information economics has shown that ahealth care service provider’s profit equals a reservation level plus aninformational rent, which increases with the degree of information asymmetry. Agood feature of this system is that service providers would have the incentiveto control costs and the insurance providers would have the incentive to reducethe degree of information asymmetry, if the mechanism was designed properly (asin the case of HMOs).

　　The requirement of government providingfunding to achieve a certain level of welfare to all citizens dramaticallychanges the nature of the game. If we still use an insurance mechanism, thegame would now involve four parties: the patients, who are only the partialpayers, the service provider, the insurer, and the government as an additionalpayer. A terrible feature of this system is that even the insurer now earns aninformational rent and it would lose its incentive to reduce the degree ofinformation asymmetry. The ending result is dramatically increased costs.

　　We can call the welfare role of thegovernment to the health care system公益性功能 [3], which is not the same as an externality nor naturalmonopoly.

　　A natural improvement to this system is tomake the government the partial fund-provider and also the insurer.

　　Please note that the system actuallyallows two different approaches. The first one is to let the market providehealth care services and second one is to let the government provide theservices directly.

　　When we select the right health caresystem for the general public, we have to choose a dominant approach. The worstsystem is a mixed one, in which the market takes the better portion of the pie(and its profit) and the government ends up having to assume responsibility forits sickest population. This approach basically destroys the insurance functionand makes the system a pure welfare system. An exception is to have thegovernment system only cover a pre-defined group, such as people over 65.

　　Let’s now compare the merits of the twosystems. The market approach still has the bad features of the three party gameand its associated moral hazard and adverse selection problems discussed above.Its most desirable features are (a) market competition will force hospitals toincrease operating efficiency (not necessarily the same thing as reducing coststo the patients); (b) the competition would encourage innovation in technologyand services; (c) it offers richer variety of services, and (d) competitionwould improve service quality. The solution of this approach to the moralhazard problem is the faith of its proponents that market competition andgovernment regulation (only the less fundamental “market” economists wouldaccept any government regulation though) would reduce the level of informationasymmetry.

　　Agency theory has shown that the mostattractive feature of the government-led approach is that it converts thethree-party game into a two-party one. The government as a funding andhealth-service provider at the same time solves the moral hazard and adverseselection problem by making the information asymmetry problem disappearcompletely. This system also has a nice feature which solves a problem that hasbothered many countries for a long time – how to support teaching hospitals andgenerating a supply of good doctors, which clearly possesses the nature of atraditional public good. A comprehensive national system can also better takeadvantage of the economy of scale and modern information technology byencouraging information collection and information sharing within the system.

　　Besides having problems as opposite to thefour nice features of the market-led system, the government-led system hasanother major potential problem. Because the government is also spending otherpeople’s money, we need strong and detailed government regulation to ensurethat its designed objectives are actually achieved in practice. This includesbuilding up a performance measurement system that is entirely different from atraditional for profit system and providing the right incentives for efficiencyenhancement and innovation.

　　Clearly, modern information economics canbe consistent with either the market approach or the government-led approach.The theory can also provide useful insight into the advantages anddisadvantages of the two systems. Strangely, this theory which is vital tounderstanding the issues related to health care reform is often missing in thedebate. A few economists in the market-led approach camp have learned andunderstood some information economics. However, the vast majority of them arecompletely ignorant of this new line of modern economics. We can speculate acouple of reasons for this unfortunate phenomenon: (a) their strong ideologicalbias led them to shut their eyes to this theory; and (b) they are incapable tounderstand this theory, because it requires a high level of proficiency inmathematics. The ending result is the sad fact that we have numerous famouseconomists who are completely ignorant of modern economics entering into thisimportant discussion and pretending that they know all the answers.

　　To summarize, economic theory and conceptsare not to blame for all the controversies in the debate. The answer to thisdifficult choice problem lies in careful, fair, and honest empirical studiesthat examine the advantages and disadvantages of different systems that havebeen tried over history and are currently employed in different countries.

　　This debate is about serious comparativestudies and basic societal value preferences such as whether the government ofa modern society should guarantee a certain level of welfare to its public. Itis not about playing the economic concept game (I have played this a little bitin this note – I have to admit!) It calls for cool-headedness, not emotionalname calling.

　　[1] It refers to the idea that a society must have amandatory mechanism to remove resources away from the hands of the governmentbecause it will spend, and sometimes waste, whatever resources it can collect.

　　[2] A Chinese term that can be roughly translated into publicinterest.

　　[3] The public interest function.

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