【作者】 柴化敏；

【导师】 朱铭来；

【作者基本信息】 南开大学 ， 保险学， 2013， 博士

【摘要】 为建立“人人享有基本医疗保障”制度,保证每个人不分地域、民族、年龄、性别、职业、收入水平,都能公平获得基本医疗卫生服务,实现“人人享有基本医疗卫生服务”的医疗卫生体系,我国的医疗卫生体制不断进行改革和完善。当前,随着我国基本医疗保险覆盖范围的扩大,覆盖城乡的全民医保体系已经基本形成。目前我国的基本医疗保障制度是以新型农村合作医疗、城镇居民基本医疗保险、城镇职工基本医疗保险和城乡医疗救助为主体,分别覆盖农村人口、城镇非就业人口、城镇就业人口和城乡困难人群,解决了部分人群医疗保险缺失的不公平问题。但是,另一方面,制度本身的设计随着实施的进一步深化也逐渐的暴露出诸多问题。由于城乡二元结构使得居民在健康水平、医疗服务的可及性、可得性存在较大差距。而不同医疗保险制度提供经济风险保护时,在医保缴费标准、待遇水平、保障范围、报销比例等设计方面方面存在较大差异。这有可能进一步拉大城乡居民对医疗服务的使用和需求差距,进而可能导致城乡居民健康水平更大差距。同时,基本医疗保险制度的新农合、城职保和城居保三大主体制度：新型农村合作医疗、城镇居民基本医疗保险和城镇职工基本医疗保险存在着制度交叉；不同的管理机构和管理体制造成了制度运行的低效率。本文正是基于以上研究背景,综合运用微观经济学、保险经济学、卫生经济学、计量经济学等方法,建立在医疗服务需求理论与医疗保险基本理论基础上,一方面,从宏观视角,描述性分析国际和国内不同医疗保险制度模式实施效果；另一方面,从微观视角,实证检验包括商业医疗保险在内的、不同类型的基本医疗保险对我国城乡居民医疗服务需求和使用的影响差异。本文首先运用微观经济学、保险经济学和卫生经济学基本理论,阐述了健康与医疗服务需求理论和医疗保险需求理论以及医疗保险对医疗服务需求的影响理论,然后分别从国外和国内研究文献中回顾总结医疗保险对治疗行为选择和医疗服务需求支出影响的实证研究结果。本文研究的重点是,利用2008年“中国健康与养老追踪调查(CHARLS)"截面数据,以45周岁以上的中老年人为研究对象,采用不同的计量方法,以新型农村合作医疗为参照组,估计不同类型的医疗保险包括：城镇职工基本医疗保险、城镇居民基本医疗保险、公费医疗和商业医疗保险以及其他类型的医疗保险,对我国城乡居民医疗服务需求和使用的影响,具体衡量指标包括个体是否治疗,治疗行为选择决策、医疗费用总支出决策和个人自付医疗费用支出决策的影响。本文的研究结果表明个体的健康状况、人口和社会经济特征等异质性因素对医疗服务需求都有显著影响。在控制了这些异质性因素以后,不同的医疗保险对个体医疗服务需求和使用的差异影响十分显著。具体分为以下三个方面：首先,利用Logit模型和Multi-Nominal Logit模型对个体治疗行为选择决策的估计结果来看,无论居民是否报告患病情况下,相比新型农村合作医疗,其他医疗保险都会提高个体治疗行为发生概率,尤其是商业医疗保险会显著提高治疗行为概率的44%；城镇职工医疗保险则会显著提高12%。其次,利用Heckman样本选择模型(two-part)对个体医疗费用总支出决策模型的估计结果看,在医疗支出发生概率方面,相比新型农村合作医疗,商业医疗保险会显著提高个体医疗支出发生概率的33%,城镇职工医疗保险则会显著提高9%。在医疗费用总支出大小方面,相比新型农村合作医疗,城镇居民医疗保险覆盖人群的个人医疗费用总支出会显著增加59%,即1844元(按平均医疗支出3111元计算)；而享有公费医疗的人群的医疗总支出会显著增加125%,即3895元(按平均医疗支出3111元计算)。同时,根据收入弹性的计算公式和计量回归结果得出全部样本的医疗支出的收入弹性为0.127。再次,利用两部分模型对个人自付医疗费用支出决策模型的估计结果看,第一,在个人自付医疗支出发生概率方面,相对新型农村合作医疗而言,商业医疗保险会降低个人自付医疗支出发生概率的2%。第二,在发生个人自付医疗费用支出情况下,相比新型农村合作医疗,商业医疗保险会显著降低个人自付医疗支出的26%,约533元(按照个人自付医疗费用支出平均2022元计算)；而城镇居民医疗保险覆盖人群的个人自付医疗支出会显著增加56%,约1131元(按照个人自付医疗费用支出平均2022元计算)。而城镇职工医疗保险和公费医疗并没有发现显著影响。第三,在个人自付医疗费用负担比例方面,不同医疗保险的影响也存在显著差异。相比新型农村合作医疗,享有公费医疗人群和城镇职工医疗保险覆盖人群的个人自付医疗负担比例都显著降低8%，商业医疗保险和城镇居民医疗保险人群的个人自付医疗费用负担比例会更高,但都并不显著。因此,本文得出以下主要结论：在控制了个体健康状况、社会经济等特征的异质性因素后,不同保障水平和筹资水平的医疗保险对城乡居民的医疗服务需求的差异影响十分显著。从治疗行为选择决策来看,相比新型农村合作医疗,城镇职工医疗保险和商业医疗保险在改善和提高个体治疗行为方面起到了更为积极的作用。从医疗需求总支出方面来看,相比新型农村合作医疗,城镇职工医疗保险和商业医疗保险提高了医疗需求总支出发生概率,而城镇居民医疗保险和公费医疗却提高了个体医疗需求总支出大小。从个人自付医疗费用支出来看,相比新型农村合作医疗,商业医疗保险降低了个人自付医疗支出发生概率,同时也会显著降低个人自付医疗费用总支出；而城镇居民医疗保险的个人自付医疗费用支出显著更高；城镇职工医疗保险和公费医疗去显著降低个人自付医疗支出负担比例。这一研究结果表明,包括商业医疗保险在内的五种医疗保险中,公费医疗处于最好的地位,城镇职工居于次好地位,商业医疗保险则仅次于城职保,城镇居民医疗保险和新型农村合作医疗则处于相对较差的地位。首先,享有公费医疗的人群医疗费用支出最高且个人自付医疗负担最低；其次为城镇职工医疗保险,显著提高个体的治疗行为发生,并在提高医疗服务需求的同时,降低个人自付医疗负担；再次是商业医疗保险,也提高了个体的治疗行为,同时降低个人自付医疗支出发生和自付医疗总支出；而新型农村合作医疗和城镇居民医疗保险覆盖人群则处于相对较差的地位,治疗行为发生概率较低且医疗需求总支出也较低,但个人自付医疗负担较重。而城镇居民医疗保险的个人医疗需求总支出和个人自负医疗支出都显著高于新型农村合作医疗,但是个人医疗负担比例也相对较高。可见由于医疗保险制度本身设计差异,导致了原本基于城乡收入和健康不平等基础之上的个体医疗服务需求和使用的不平等,进一步加剧;而医疗服务需求和使用的不平等,会进一步拉大城乡居民健康的不平等和收入的不平等,最终会影响到整个社会经济发展和稳定。因此,应采取有效措施,缩小不同医疗保险制度之间保障水平的差异,并降低个人自付医疗费用负担,真正实现全体国民享有的公平的、平等的、有效的基本卫生服务,最终提高全体国民的健康水平。更多还原

【Abstract】 Nowadays "universal health care" is the aim of the public health insurance program in China, that is, to ensure equity, able to pay and basic health care available to all residents in the rural and urban. China has been making great efforts on the road of universal coverage of public health insurance since the reform.China is currently in the midst of a period of transforming its health-care system. Three main types of medical insurance plan operated in China:Urban Employee Medical Insurance (UEMI), Urban Resident Medical Insurance (URME) and New Cooperative Insurance (NCMI). However, public health insurance’s universal coverage does not mean "universal health care". Because based on the universal coverage,"universal health care" requires health care be adequate, able to pay and equity available to all residents in the rural and urban. This means people with same equal needs for health care have equal utilization; different levels of ill health have appropriately different levels of utilization, whatever their occupations, income, education and other socio-demographic characteristics. And on the other hand, with public health insurance, people should be protected from the financial risks and impoverishment of illness. Currently, multi health insurance schemes are targeted to people with different income and occupations and the basic benefit package varies widely in different schemes across the rural and urban. With regard to NCMI, as a result of limited funding, coverage is typically shallow. Many services are not, or only partially, covered, deductibles are high, ceilings are low, and coinsurance rates are high. Regarding to the UEMI, the expanded coverage to private sector employees and pools its risk at the municipal level, which provides more stable financing. With regard to the URMI, it is a voluntary program aimed at providing health insurance to primary and secondary school students, very young children, and other unemployed urban residents. The goal of URMI is to eliminate medical impoverishment. On average, the URMBI policy covers not half of related inpatient medical costs and some outpatient services for chronic or fatal diseases. The GIS is the best public health insurance available in China in terms of generosity. The questions are arouse that how about the effect of multi-health insurance schemes on the health care utilization and financial protection for all residents in rural and urban.Within this background, this thesis is based on economics, economics of insurance, economics of health and health care and econometrics. The thesis established the theory of demand health and health insurance. Then different types of health insurance system in the world and the health care utilization consequences were examined respectively. Finally, the thesis empirically studied the effect of various types of health insurance on the individual health care demands.Based on the literature review of the effect of health insurance on the health care utilization, the paper employed data from the2008China Health and Retirement Longitudinal Study (CHARLS), to estimates various types of health insurance on the health care demand of people over45years old. The various types of health insurance refers to UEMI, URME, NCMI, Government Medical Insurance (GMI), private health insurance and others. The health care utilization is indicated by the following index:whether to care, the choice of various types of care, Medical care expenditure and out-of-pocket expenditure.The main results are as follows. Individual heterogeneity, i.e. health status, socio-demographic characteristics, accounts significantly for much of the variation in the health care utilization. After controlling for individual heterogeneity, various types of health insurance have a significant impact on the health care demand. First, compared to NCMI, all kinds of health insurance are positively related to the probability of care, particularly, private health insurance is44%more likely to care and UEMI is12%more like to care. Second, people who cared, no evidence showed that health insurance is significantly related to the choice of treat themselves, outpatient or inpatient, both treat themselves and outpatient or inpatient. The exception is, compared to treat themselves, adults with UEMI are8%less likely to choose both treat themselves and outpatient or inpatient than adults with NCMI. Third, with regard to the probability of Medical care expenditure zero above, compared with NCMI, private health insurance incurred a33%higher probability and UEMI incurred a9higher probability. With regard to the Medical care expenditure, URMI has a59%more expenditure (1844RMB, with average Medical care expenditure equals3111RMB); while GMI has a125%higher expenditure (3895RMB). The health care demand elasticity of income is0.127. Fourth, with respect to the probability of OOP zero above, individual with OOP accounts for98%of the sample size. No evidence suggests that health insurance is significantly related to the probability of OOP zero above as a large majority of people have occurred OOP. The exception is people with private health insurance are2%lower to have OOP than people with NCMI. Regarding to OOP, compared to NCMI, people covered by URMI have a26%higher OOP (533RMB, with average of OOP is2022RMB in the sample); while people with private health insurance have a56%lower OOP (1131RMB). With regard to the share of OOP in Medical care expenditure, compared to NCMI, people covered by UEMI and GMI both have a8%lower share of OOP.The findings suggest that multi-health insurance schemes significantly have an impact on the health care utilization and financial protection for residents in rural and urban. In terms of generosity, the GIS is the best public health insurance and increases the Medical care expenditure and decreases the OOP financial burden. However, on the contrary, NCMI with many services only partially covered, higher deductibles, lower ceilings and high coinsurance rates, incurs a lower expenditure and a higher share of OOP, and this is almost true to URMI. And the impact of the UEMI is in the medium. Greater attention to the policies and interventions that may reduce the difference of basic benefit package to promote the equality of public health services to move towards universal coverage is warranted.更多还原