随着全面脱贫攻坚的完成以及乡村振兴战略的实施,我国农村和农业发生了重大变化,从事农业以及在农村居住的人口快速下降,给我国城乡居民医保的制度结构及筹资带来重大挑战。本文通过梳理德国农民的参保机制和农民医疗保险,以期为完善我国城乡居民医保参保机制提供政策启示。研究发现,德国农民医疗保险筹资上采取“一制多档”,缴费多少依据农场土地价值高低;家庭成员联带参保,成人保费减半、儿童保费减免四分之三;设有保费返还机制;待遇支付不区分医疗类别。政府投入占农民医疗保险收入的比例常年稳定在50%以上。德国经验带给我国以下政策启示：农民参保缴费可以与收入相挂钩;为激励参保可对待遇“做加法”,适当提高门诊保障水平;结合我国实际,未来还需要考虑职工医保和城乡居民医保的整合,探索更为灵活的参保机制。

With the completion of the comprehensive poverty alleviation and the implementation of the rural revitalization strategy, significant changes have occurred in China's rural areas and agriculture. The population engaged in agriculture and living in rural areas has rapidly declined, posing significant challenges to the institutional structure and financing of medical insurance for urban and rural residents in China. This article attempts to provide policy insights for improving the medical insurance participation mechanism for urban and rural residents in China by reviewing the participation mechanism of German farmers and their medical insurance. Research has found that the financing of German farmers' medical insurance adopts a "one system, multiple levels" approach, and the amount of payment is based on the value of the farm land. Family members participating in insurance together will have their adult premiums halved and their children's premiums reduced by three-quarters, also they establish a premium refund mechanism and do not differentiate between medical categories regarding the payment of benefits. The proportion of government investment in farmers' medical insurance revenue has remained stable at over 50%. The German experience provides the following policy insights for China. Farmers' insurance premiums can be linked to their income. To incentivize participation in insurance, benefits can be added and the level of outpatient security can be appropriately improved. Based on the actual situation in China, it is necessary to consider the integration of employees’ medical insurance and urban and rural residents’ medical insurance in the future, and explore more flexible participation mechanisms.