（原編者按：深化公立醫院改革，首先要有正確的理論指導。當前，一些觀點用過于簡單的競爭性市場一般均衡模型解釋公立醫院改革，得出似是而非的結論。
20世紀60年代以來，西方經濟學也發生了深刻變化。以信息經濟學、契約理論和機制設計為主要代表，過去的市場-政府二分法已經被大大超越。但是，由于這些方法尚未被我國大多數學者所熟悉，從而制約了對公立醫院的認識。
本文是許定波教授針對一位經濟學研究者“經濟學教科書中沒有公益性概念”的謬論所寫的文章。深入淺出地用現代經濟學的理論講述了如何理解公立醫院。
本文原文由許教授用英文撰寫，原題為“On the Great Debate on Reforming China’sHealth Care System-- Some possibly biased “objective” comments”，中文版由國務院發展研究中心江宇翻譯）
正文
圍繞中國醫改方向的大辯論，已經持續多年，今年4月，中國政府正式明確了“政府主導”的醫改方向。但是，關于醫改的辯論并未偃旗息鼓，反而出現了更濃的火藥味。一方面，廣大公眾感到歡欣鼓舞，另一方面，經濟學家卻進一步分化成觀點針鋒相對的陣營。許多局外人被搞糊涂了——經濟學家的分歧到底在哪里?
對于那些反對“政府主導”的人，我十分贊賞他們的信仰堅定，不管現實世界如何變化，他們始終堅持自己的觀點，堅貞不渝。他們對市場充滿信任，而對政府充滿擔心，擔心政府配置資源效率不高，擔心政府主導的醫改會像其他福利項目那樣帶來過高的成本。他們認為，對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力，因為政府會把自己掌握的一切資源都花掉或者浪費掉，弗里德曼的這個理論，在世界各地的學者和公眾當中，都有大批的支持者，中國那些支持市場主導醫改的經濟學家，無疑對此也是認同的。
然而，和德高望重的弗里德曼他老人家相比，中國一些支持市場主導醫改的經濟學家實在讓人大失所望。他們雖然在討論中也不斷提到經濟學概念和理論，但給我們的感覺是，許多人對當代經濟學的最新進展一片茫然，誠所謂“不知有漢，無論魏晉”也。因為掌握的分析手段有限，所以他們不能夠充分理解醫療衛生的特性，反而把他們自己沒聽說過的——比如“醫療衛生的公益性”，當成是“錯誤的經濟學理論”。一些經濟學家在討論中喜歡使用花哨的概念，故作神秘和高深，但是卻不愿意花時間搞清楚，醫療衛生的真正特性是什么。
我這篇文章要說的是，醫療衛生和其他領域有哪些本質區別?我會介紹現代經濟學中對理解醫療衛生問題十分重要的一個分支，以此來說明，那種認為政府主導就是和現代經濟學矛盾的觀點，恰恰是對現代經濟學不了解造成的。現代經濟學與市場和政府主導都不矛盾。社會最終選擇政府還是市場，取決于這個社會要實現什么樣的目標。
過去半個世紀，經濟理論最偉大的進展是信息經濟學(又叫代理理論)，幾代經濟學家把畢生精力用于信息經濟學的研究，Leo Hurwicz、Roger B. Myerson、Eric S.Maskin作為其中的杰出代表，相繼獲得諾獎。信息經濟學有助于理解中國和其他國家關于醫療衛生體制的爭論。
我們討論的起點是：醫療衛生和制造業、服務業等其他行業有一個根本區別：醫療衛生需要風險分擔（risk sharing)。醫療服務是由疾病帶來的需求，而疾病并不是平均發生在每個人身上，與人的收入也沒有必然聯系，在飲食業，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。
風險分擔最傳統的方式是建立一個一體化的保險市場，所有潛在的患者都參加保險。但是，保險機制要充分發揮作用，需要一個前提，即在參加保險的時候，人和人之間是同質的。不幸的是，現實并不那么簡單：按照收入高低，社會分為不同的收入階層。盡管一些市場原教旨主義者不同意，但是絕大多數生活在現代文明社會中的人都承認，即使最弱勢的群體也應該享有基本的醫療服務。
因此，盡管醫療體系和傳統的保險都具有風險分散的功能，但是除此之外，醫療體系還具有福利功能。一個社會必須通過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療服務。
如果所有人在參加保險前是同質的(疾病風險和收入都相同)，那么一個良好的保險體系的效率不會比政府主導醫療服務來得差。保險體系是一個三方博弈：患者、醫療服務提供方、保險方(如商業保險公司)。信息經濟學告訴我們，醫療服務提供者的利潤等于社會保留利潤率（reserved profit）加上信息租金（informational rent)，其中信息租金隨著醫療服務方和付費方之間信息不對稱的程度而增加。所以，一個好的保險制度應該是這樣的：醫療服務提供者有動力控制成本;保險者有動力降低信息不對稱的程度。如果制度設計合理，這是可以達到的(美國的HMOs是一個例子)。
但是，前面說過，醫療保險還有福利功能，政府必須保證所有居民都能享受不低于一定水平的醫療服務。這個要求就可以叫做醫療衛生的“公益性”，這和外部性、自然壟斷等是不一樣的。公益性的要求，從本質上改變了博弈的規則。如果我們仍然采取一個保險體系，博弈就變為四方博弈：患者、服務提供者、保險者、政府。其中，患者承擔部分醫療成本，剩下的政府承擔。這個體系會出現一個可怕的問題：因為政府要兜底，所以保險者和政府之間也存在著信息不對稱，保險者也有了信息租金，同時卻失去了控制信息不對稱的動力。結果就是急劇上升的成本。
那么，既然政府的介入導致成本上升，這是不是否定政府主導的理由呢?不是。因為保證人人享有基本醫療服務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，導致成本上升。解決這個問題的辦法是，讓政府同時承擔出資者和保險者的職能。
讓政府同時承擔出資者和保險者的職能，又有兩種途徑。一是政府舉辦社會醫療保險，由市場提供醫療服務(市場提供);二是政府直接舉辦和提供服務(政府提供)。社會必須要在這兩種途徑中選擇一種占主導地位，騎墻是不行的。最壞的制度，就是兩種途徑的混合：市場把最肥的那部分蛋糕(收入高、疾病風險低的人群)挑選出來，賺取利潤;而政府不得不為最窮、最病的那部分人承擔責任。對于食品、住房這種不存在風險分擔的產品，高端和低端之間的市場分層是起作用的，政府只管窮人是可以的。但是，在醫療領域這么做，就完全破壞了風險分擔的機制。
既然不能騎墻，就讓我們比較一下這兩種途徑的優劣。
先說市場提供。市場提供的途徑，存在三方博弈中存在的逆向選擇和道德風險的問題。而其優勢在于：(1)競爭能夠促進醫院提高運行效率(但是，運行效率提高未必意味著降低患者的成本);(2)競爭能夠促進技術創新;(3)提高了服務的多樣性;(4)競爭提高服務質量。那么，逆向選擇和道德風險的問題能否解決?市場主導論的支持者始終不渝地相信，通過競爭和政府監管能夠降低信息不對稱的程度(盡管只有不太市場原教旨主義的經濟學家才接受政府監管)。
再說政府提供。代理理論表明，政府提供最有吸引力的特點是，把原來的三方博弈變成了兩方博弈。政府既是支付者，又是醫療服務的提供者。政府同時承擔這兩個角色，解決了道德風險和逆向選擇的問題，三方變成兩方之后，原來存在于付費者和服務提供者之間的信息不對稱問題就不存在了，把付費者和服務提供者之間的交易成本內部化了。這種體系還很好地解決了長期困擾許多國家的教學醫院撥款和培育優秀醫生的問題，教學醫院和醫療人才培育是具有傳統的公共品特性的。一個完整的國家醫療服務體系，還可以很好地發揮現代醫學的規模效益和信息技術的優勢，在系統內部促進信息收集和共享，大幅度提高微觀管理的績效。
市場提供的四個長處，相應地是政府主導體系的短處。除此之外，政府主導體系還有一個潛在的問題：政府是納稅人的代理人，需要通過強有力而精細的監督，才能保障政策目標在現實中得到貫徹。這需要對整個醫療衛生系統建立一個績效考核系統，徹底告別傳統的以營利為目標的考核辦法，真正把健康績效的提高作為考核的激勵。
很明顯，現代信息經濟學不僅與政府主導和市場主導都不矛盾，而且可以幫助我們深入了解兩種體系的優勢和劣勢，國際上用信息經濟學研究醫療衛生的文獻也越來越多。但奇怪的是，對于理解醫療衛生如此重要的一個經濟學分支，在中國醫改的大辯論中卻很少有人提到。在市場主導派的陣營，有一些經濟學家似乎學過一些信息經濟學，但是大部分人完全不了解這個經濟學的前沿領域。
原因在哪里?我可以設想一些原因：(1)意識形態上根深蒂固的偏見，使他們對理論的新進展視而不見;(2)他們的能力有限，不足以理解甚至了解這一新領域，信息經濟學要求熟練的數理基礎。悲哀的是，許多介入醫改討論的“著名經濟學家”，實際上對現代經濟學前沿一無所知，還假裝他們懂得一切。需要強調的是，我并非先入為主地支持任何一種觀點，我只是提供一個分析框架，并且指出，任何討論都需要克服偏見和知識面的局限性。
總結一下，在辯論中指責任何概念，都不是聰明的辦法。對于醫改的道路這樣一個重大問題的抉擇，需要從偏見和意識形態中走出來，需要對歷史上試驗過和現實中存在的不同制度進行深入、細致、誠實和不帶偏見的實證研究。
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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