目的: 从卫生经济学视角系统剖析1998—2025年我国全民医保制度演进的内在逻辑、经济效应与运行规律,为医保高质量发展提供经济学依据。方法: 基于1998—2025年15项宏观时序指标,构建覆盖、筹资、基金、资源、产出五维分析框架,综合运用弹性分析、长期均衡分析、传导机制识别等方法,揭示医保制度演进的经济机制。结果: 28年间,医保参保率从1.5%升至94.7%,实现全民覆盖;卫生总费用占GDP比重从4.28%升至6.74%,个人卫生支出占比从60.1%降至26.8%,筹资结构实现根本性转型;卫生消费弹性系数呈现明显波动特征,受政策调整和外部冲击影响显著;覆盖扩大与基金扩张的传导机制存在阶段性差异,2012年后改革重心从覆盖面扩张转向筹资水平提升;在职退休比从4.09降至2.60,代际平衡压力持续加大;三级医院床位占比接近半数,资源配置倒金字塔结构导致效率损失;平均预期寿命提升8.42岁,健康人力资本投资收益显著。结论: 中国全民医保制度实现了从个人负担向社会筹资的结构性转型,取得了显著成效,但也面临代际平衡、费用控制、资源配置效率等深层经济学挑战。下一阶段应通过优化筹资机制、深化支付改革、矫正资源失衡、强化健康投资等路径,推动医保制度从规模扩张向质量效益转型。

Objective: The paper attempts to systematically analyze the internal logic, economic effects, and operational patterns of the evolution of China's universal medical insurance system from 1998 to 2025 from the perspective of health economics, providing economic evidence for high-quality development of medical insurance. Methods: Based on 15 macro indicators from 1998 to 2025, elasticity analysis, long-run equilibrium analysis, and identification of the transmission mechanisms were applied to construct an analysis framework of "coverage-financing-funds-resources-output", revealing the economic mechanisms underlying the evolution of the medical insurance system. Results: Over 28 years, medical insurance enrollment climbed from 1.5% to 94.7%, achieving universal coverage. Total health expenditure rose from 4.28% to 6.74% of GDP, while out-of-pocket spending dropped from 60.1% to about 26.8%, representing a fundamental shift in financing structure. The elasticity of health consumption fluctuated markedly, significantly affected by policy adjustments and external shocks. The transmission mechanisms between coverage expansion and fund growth differed across phases. After 2012, reform priorities shifted from coverage expansion to financing level improvement. The active-contributor-to-retiree ratio fell from 4.09 to 2.60, heightening intergenerational balance pressure. Tertiary hospital beds approached half of the total, and the inverted-pyramid allocation of resources caused efficiency losses. Average life expectancy rose by 8.42 years, reflecting substantial returns on health human capital investment. Conclusion: China's universal medical insurance system has completed a structural shift from individual to social financing, with notable achievements. However, it faces profound economic challenges, including intergenerational balance, cost containment, and resource allocation efficiency. Going forward, reforms should focus on optimizing financing mechanisms, deepening payment reform, correcting resource imbalances, and strengthening health investment, thereby shifting the system from scale expansion toward quality-and-efficiency improvement.