（原编者按：深化公立医院改革，首先要有正确的理论指导。当前，一些观点用过于简单的竞争性市场一般均衡模型解释公立医院改革，得出似是而非的结论。
20世纪60年代以来，西方经济学也发生了深刻变化。以信息经济学、契约理论和机制设计为主要代表，过去的市场-政府二分法已经被大大超越。但是，由于这些方法尚未被我国大多数学者所熟悉，从而制约了对公立医院的认识。
本文是许定波教授针对一位经济学研究者“经济学教科书中没有公益性概念”的谬论所写的文章。深入浅出地用现代经济学的理论讲述了如何理解公立医院。
本文原文由许教授用英文撰写，原题为“On the Great Debate on Reforming China’sHealth Care System-- Some possibly biased “objective” comments”，中文版由国务院发展研究中心江宇翻译）
正文
围绕中国医改方向的大辩论，已经持续多年，今年4月，中国政府正式明确了“政府主导”的医改方向。但是，关于医改的辩论并未偃旗息鼓，反而出现了更浓的火药味。一方面，广大公众感到欢欣鼓舞，另一方面，经济学家却进一步分化成观点针锋相对的阵营。许多局外人被搞糊涂了——经济学家的分歧到底在哪里?
对于那些反对“政府主导”的人，我十分赞赏他们的信仰坚定，不管现实世界如何变化，他们始终坚持自己的观点，坚贞不渝。他们对市场充满信任，而对政府充满担心，担心政府配置资源效率不高，担心政府主导的医改会像其他福利项目那样带来过高的成本。他们认为，对待政府就要像弗里德曼(Milton Friedman)提出的“困兽(starving the beast)”那样，限制政府配置资源的权力，因为政府会把自己掌握的一切资源都花掉或者浪费掉，弗里德曼的这个理论，在世界各地的学者和公众当中，都有大批的支持者，中国那些支持市场主导医改的经济学家，无疑对此也是认同的。
然而，和德高望重的弗里德曼他老人家相比，中国一些支持市场主导医改的经济学家实在让人大失所望。他们虽然在讨论中也不断提到经济学概念和理论，但给我们的感觉是，许多人对当代经济学的最新进展一片茫然，诚所谓“不知有汉，无论魏晋”也。因为掌握的分析手段有限，所以他们不能够充分理解医疗卫生的特性，反而把他们自己没听说过的——比如“医疗卫生的公益性”，当成是“错误的经济学理论”。一些经济学家在讨论中喜欢使用花哨的概念，故作神秘和高深，但是却不愿意花时间搞清楚，医疗卫生的真正特性是什么。
我这篇文章要说的是，医疗卫生和其他领域有哪些本质区别?我会介绍现代经济学中对理解医疗卫生问题十分重要的一个分支，以此来说明，那种认为政府主导就是和现代经济学矛盾的观点，恰恰是对现代经济学不了解造成的。现代经济学与市场和政府主导都不矛盾。社会最终选择政府还是市场，取决于这个社会要实现什么样的目标。
过去半个世纪，经济理论最伟大的进展是信息经济学(又叫代理理论)，几代经济学家把毕生精力用于信息经济学的研究，Leo Hurwicz、Roger B. Myerson、Eric S.Maskin作为其中的杰出代表，相继获得诺奖。信息经济学有助于理解中国和其他国家关于医疗卫生体制的争论。
我们讨论的起点是：医疗卫生和制造业、服务业等其他行业有一个根本区别：医疗卫生需要风险分担（risk sharing)。医疗服务是由疾病带来的需求，而疾病并不是平均发生在每个人身上，与人的收入也没有必然联系，在饮食业，可以富人吃燕窝，穷人吃米饭，但是穷人和富人都有可能得大病。
风险分担最传统的方式是建立一个一体化的保险市场，所有潜在的患者都参加保险。但是，保险机制要充分发挥作用，需要一个前提，即在参加保险的时候，人和人之间是同质的。不幸的是，现实并不那么简单：按照收入高低，社会分为不同的收入阶层。尽管一些市场原教旨主义者不同意，但是绝大多数生活在现代文明社会中的人都承认，即使最弱势的群体也应该享有基本的医疗服务。
因此，尽管医疗体系和传统的保险都具有风险分散的功能，但是除此之外，医疗体系还具有福利功能。一个社会必须通过直接或者间接的方式，保证所全体民众都能享有一定水平的医疗服务。
如果所有人在参加保险前是同质的(疾病风险和收入都相同)，那么一个良好的保险体系的效率不会比政府主导医疗服务来得差。保险体系是一个三方博弈：患者、医疗服务提供方、保险方(如商业保险公司)。信息经济学告诉我们，医疗服务提供者的利润等于社会保留利润率（reserved profit）加上信息租金（informational rent)，其中信息租金随着医疗服务方和付费方之间信息不对称的程度而增加。所以，一个好的保险制度应该是这样的：医疗服务提供者有动力控制成本;保险者有动力降低信息不对称的程度。如果制度设计合理，这是可以达到的(美国的HMOs是一个例子)。
但是，前面说过，医疗保险还有福利功能，政府必须保证所有居民都能享受不低于一定水平的医疗服务。这个要求就可以叫做医疗卫生的“公益性”，这和外部性、自然垄断等是不一样的。公益性的要求，从本质上改变了博弈的规则。如果我们仍然采取一个保险体系，博弈就变为四方博弈：患者、服务提供者、保险者、政府。其中，患者承担部分医疗成本，剩下的政府承担。这个体系会出现一个可怕的问题：因为政府要兜底，所以保险者和政府之间也存在着信息不对称，保险者也有了信息租金，同时却失去了控制信息不对称的动力。结果就是急剧上升的成本。
那么，既然政府的介入导致成本上升，这是不是否定政府主导的理由呢?不是。因为保证人人享有基本医疗服务是政府不可推卸的职能。政府履行这一公益性职能，三方博弈变成四方博弈，导致成本上升。解决这个问题的办法是，让政府同时承担出资者和保险者的职能。
让政府同时承担出资者和保险者的职能，又有两种途径。一是政府举办社会医疗保险，由市场提供医疗服务(市场提供);二是政府直接举办和提供服务(政府提供)。社会必须要在这两种途径中选择一种占主导地位，骑墙是不行的。最坏的制度，就是两种途径的混合：市场把最肥的那部分蛋糕(收入高、疾病风险低的人群)挑选出来，赚取利润;而政府不得不为最穷、最病的那部分人承担责任。对于食品、住房这种不存在风险分担的产品，高端和低端之间的市场分层是起作用的，政府只管穷人是可以的。但是，在医疗领域这么做，就完全破坏了风险分担的机制。
既然不能骑墙，就让我们比较一下这两种途径的优劣。
先说市场提供。市场提供的途径，存在三方博弈中存在的逆向选择和道德风险的问题。而其优势在于：(1)竞争能够促进医院提高运行效率(但是，运行效率提高未必意味着降低患者的成本);(2)竞争能够促进技术创新;(3)提高了服务的多样性;(4)竞争提高服务质量。那么，逆向选择和道德风险的问题能否解决?市场主导论的支持者始终不渝地相信，通过竞争和政府监管能够降低信息不对称的程度(尽管只有不太市场原教旨主义的经济学家才接受政府监管)。
再说政府提供。代理理论表明，政府提供最有吸引力的特点是，把原来的三方博弈变成了两方博弈。政府既是支付者，又是医疗服务的提供者。政府同时承担这两个角色，解决了道德风险和逆向选择的问题，三方变成两方之后，原来存在于付费者和服务提供者之间的信息不对称问题就不存在了，把付费者和服务提供者之间的交易成本内部化了。这种体系还很好地解决了长期困扰许多国家的教学医院拨款和培育优秀医生的问题，教学医院和医疗人才培育是具有传统的公共品特性的。一个完整的国家医疗服务体系，还可以很好地发挥现代医学的规模效益和信息技术的优势，在系统内部促进信息收集和共享，大幅度提高微观管理的绩效。
市场提供的四个长处，相应地是政府主导体系的短处。除此之外，政府主导体系还有一个潜在的问题：政府是纳税人的代理人，需要通过强有力而精细的监督，才能保障政策目标在现实中得到贯彻。这需要对整个医疗卫生系统建立一个绩效考核系统，彻底告别传统的以营利为目标的考核办法，真正把健康绩效的提高作为考核的激励。
很明显，现代信息经济学不仅与政府主导和市场主导都不矛盾，而且可以帮助我们深入了解两种体系的优势和劣势，国际上用信息经济学研究医疗卫生的文献也越来越多。但奇怪的是，对于理解医疗卫生如此重要的一个经济学分支，在中国医改的大辩论中却很少有人提到。在市场主导派的阵营，有一些经济学家似乎学过一些信息经济学，但是大部分人完全不了解这个经济学的前沿领域。
原因在哪里?我可以设想一些原因：(1)意识形态上根深蒂固的偏见，使他们对理论的新进展视而不见;(2)他们的能力有限，不足以理解甚至了解这一新领域，信息经济学要求熟练的数理基础。悲哀的是，许多介入医改讨论的“著名经济学家”，实际上对现代经济学前沿一无所知，还假装他们懂得一切。需要强调的是，我并非先入为主地支持任何一种观点，我只是提供一个分析框架，并且指出，任何讨论都需要克服偏见和知识面的局限性。
总结一下，在辩论中指责任何概念，都不是聪明的办法。对于医改的道路这样一个重大问题的抉择，需要从偏见和意识形态中走出来，需要对历史上试验过和现实中存在的不同制度进行深入、细致、诚实和不带偏见的实证研究。
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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