中国人口老龄化对医疗卫生支出的影响
摘要
人口结构的变化、老龄化程度的提高将引致医疗卫生服务需求的变化,从而影响医疗卫生支出,并成为医疗卫生体制的一大挑战。通常来说,老龄人口健康折旧率高,对医疗卫生服务的需求较大,因此随着老龄化程度的提高,医疗卫生支出应该相应增长。但是另一方面,收入水平、医疗保障制度、医疗卫生资源供给等各方面因素将会影响医疗卫生资源的配置从而影响对老龄人口医疗卫生服务需求的满足程度,因此可能出现随着老龄化程度的提高,医疗卫生支出并不会相应增长的现象。最终老龄化与医疗卫生支出的关系要综合考虑上述各方面因素而定。
在我国,作为一个未富先老的人口大国,尤其在特有的城乡二元结构下,是否与通常认为随着老龄化程度的提高,医疗卫生支出会相应增长,这是值得探讨的一个重要问题。现有文献对这一问题的研究较少,且没有深入回答以下三个问题：在过去20年中,老龄化(尤其城乡老龄化)与医疗卫生支出的关系如何?老龄化影响医疗卫生支出的机制有哪些?在未来城乡融合趋势下,城乡老龄化对医疗卫生支出的影响趋势如何?为了回答上述问题,本文采用八个章节予以分析。首先从客观事实特征、文献综述出发梳理不同国家老龄化与医疗卫生支出的关系,厘清老龄化因素在医疗卫生支出中的作用以及影响机制。而后首次采用我国数据(宏观层面的省级面板数据(2002-2008年)和微观层面的CHNS混合截面数据(1991-2009年))从城乡差异的视角进行实证计量分析,以验证在我国现阶段城乡老龄化(年龄)是否是医疗卫生支出的决定因素?评估老龄化(年龄)因素在医疗卫生支出增长中的作用,探究老龄化(年龄)影响医疗卫生支出的机制等;并建立预测模型,在未来城乡融合的趋势下,对城乡老龄化进程下的医疗卫生支出趋势进行模拟预测。最后提出针对性的政策建议思考。
实证计量分析作为本文的主体内容以及创新性的体现,主要围绕医疗卫生支出中的门诊、住院支出进行分析,发现以下几点主要结论。
一是在总体上,上世纪90年代我国老龄人口的医疗卫生服务需求并没有得到有效满足,老龄化并没有推动医疗卫生支出增长,但在本世纪初开始老龄化与医疗卫生支出呈显著的正相关性,老龄化的医疗卫生支出弹性为0.278。另一方面,目前老龄化在医疗卫生支出增长中的影响程度有限,远低于收入、医疗技术。
二是现阶段城镇老龄人口的医疗卫生服务需求得到了一定程度的满足,推动了医疗卫生支出的增长(城镇老龄化的医疗卫生支出弹性为0.207)。在农村,由于经济发展水平较低、医疗保障体系不健全、医疗资源供给较为匮乏等原因导致老龄人口的医疗卫生服务需求并没有得到有效满足,因此,现阶段农村老龄化并没有影响医疗卫生支出,甚至随着老龄化程度的提高,其自费医疗卫生支出下降。
三是从年龄组的具体影响效应来看,城镇老龄组的患病概率、对医疗卫生支出的影响效应均大于农村老龄组。在生病且有医疗卫生支出的样本中,相比于城镇18-29岁年龄组,城镇60-69岁、70-79岁老龄组的医疗卫生支出分别增加了59.1%和76.4%,而农村却只分别增加了53.8%和55.1%。另一方面,健康状况显著影响年龄的具体影响效应,在城镇,一旦控制慢性病,老龄组对医疗卫生支出的影响效应将进一步增强.而农村却在减弱.某种程度表明,相比于农村,城镇患病老龄人口能得到有效的治疗,而农村可能存在有病不就医情况。
四是老龄化影响医疗卫生支出的机制主要通过医疗技术、医疗保险等资源向老龄人口倾斜,从而有效满足其医疗卫生服务需求。另一方面从微观个体来看,收入水平、健康状况会影响医疗卫生服务需求从而影响医疗卫生支出。对于农村来说,政府财政投入、收入水平、受教育程度提高将会极大增强老龄人口的医疗卫生服务需求满足程度。
五是从医疗卫生支出趋势来看.至2030年医疗卫生支出占GDP比重将达到8%-10.6%,至2050年将有40%的医疗资源配置于老龄人口。如果以城镇老龄化的医疗卫生服务需求满足程度为基准,农村老龄人口也得到同等程度的满足,则会使医疗卫生支出占GDP比重在2010-2030年间提高0.07-1.6个百分比。另一方面城乡老龄化进程的加快将促使医疗卫生支出占GDP比重上升,而放开人口政策、实施有效的医疗成本控制政策将有助于控制医疗卫生支出过快增长。
本文的政策含义主要有两方面。首先,基于未来城乡融合、城乡医疗服务差异缩小,农村老龄化将会推动医疗卫生支出快速增长,因此政策制定者在采取各项措施控制医疗卫生支出增长的同时,需要正视农村老龄人口医疗服务需求得到满足后医疗卫生支出增长的可能性。其次,虽然目前老龄化对医疗卫生支出的影响并不是很大,但是这并不意味着老龄化因素不重要,随着未来老龄化程度的加剧,对医疗卫生支出的影响将会日渐增大,未来将需要更多的医疗卫生资源向老龄人口(尤其农村老龄人口)倾斜。
正是基于此,未来需要充分把握我国人口结构变化特点,在采取有效措施控制医疗卫生支出快速增长的同时,又要有效满足老龄人口(尤其农村地区)的医疗卫生服务需求。具体来说,未来要提倡健康老龄化,加强各类医疗卫生资源有效配置力度,在健康管理、财政投入、护理保障体系、医疗保险体系等方面加强对老龄人口倾斜,从而及时有效应对老龄化对现有医疗卫生体制所产生的挑战。
The change of population structure and the rapid ageing process lead to the change of health care demand and health care expenditure and have been a big challenge for health care system. The ageing has a higher health depreciation rate and a stronger demand for health care, so health care expenditure will grow with the deepening of the ageing. However, some factors such as good economic conditions, adequate health care resource supply and so on have influence on the allocation of health care resource and the ageing's health care demand, so maybe health care expenditure will decline with the deepening of the aging. Therefore the relationship between the ageing and health care expenditure is obscure.
As a getting old before being rich developing country with a great population and urban-rural dual structure, whether ageing will lead to the growth of health care expenditure in our country is worthy of further discussion. Existing literatures have little attention on the relationship between ageing and health care expenditure and haven't answered the following three questions:what has been the real relationship between ageing and health care expenditure in the past20years, especially based on the urban-rural difference? How's the mechanism between ageing and health care expenditure? Will ageing accelerate health care expenditure in the future with the urban-rural composition? Eight chapters will be employed to answer the above-mentioned three questions in this study. Firstly, based on the objective facts and past literatures, we systematically review the relationship between ageing and health care expenditure in different countries, explore the mechanism between ageing and health care expenditure, analyse ageing's contribution to the growth of health care expenditure. Secondly, we use provincial panel data (2002-2008) at macro level and CHNS pooled cross-sectional data (1991-2009) at micro level to test whether ageing is one of the determinants of health care expenditure, estimate ageing's contribution, explore the mechanism between ageing and health care expenditure. Meanwhile, we set the simulation model to forecast the health care expenditure in the future. Finally, we put forward some corresponding suggestions.
Econometric analysis is the main content and innovative point. It targets outpatient and inpatient as some types of health care expenditure and its results are as followings.
First, the ageing's health care demand has not been met which has not accelerated health care expenditure in the late1990s. However, ageing has a positive relationship with the health care expenditure since the21st century. Ageing contribution to the growth of health care expenditure is limited, less than income, medical technology.
Second, from the urban-rural difference, the demand for urban ageing's health care has been met which drove up the health care expenditure. Meanwhile, in rural, ageing has little relationship with the health care expenditure because some factors such as a low economic development level, imperfect medical security system, scarce medical resource supply and so on can't meet the rural ageing's health care demand. Even the rural ageing has negative relationship with real per capita out-of-pocket health expenditure.
Third, more and more medical resource is allocated to the ageing by medical technology and medical insurance system which will meet the ageins's health care demand. On the other hand, from the micro individual level, income and health will impact the demand for health care and health care expenditure. In rural, income, education, government's financial input will make the ageing easier to obtain health care service.
Fourth, from the trend of health care expenditure, the ratio between health care expenditure and GDP will reach about8%-10.6%in2030,40percent of all medical resource will be allocated to the ageing in2050. If the rural ageing has the same satisfaction with the urban ageing in the demand for health care, the ratio between health care expenditure and GDP will enhance0.07-1.6percent. The rapid ageing process will accelerate the ratio between health care expenditure and GDP, however, the health care expenditure will be controlled by abandoning one-child policy and effective medical cost-control.
The policy meanings in this study are as followings. First, based on the urban-rural composition and decreasing gaps between urban and rural, the rural ageing will accelerate the rapid growth of health care expenditure, so the policy makers will take some effective measures to tackle the rapid growth of health care expenditure and have a proper recognition of the higher probability of the rapid growth of health care expenditure in rural. Second, ageing's contribution to the growth of health care expenditure is limited, but it will play a more important role in the growth of health care expenditure with the rapid ageing process. In the future, it needs more medical resource allocated to the ageing.
Based on the above-mentioned, we should have a good grasp of population structure trait. On one hand, some effective measures will be taken to tackle the rapid growth of health care expenditure, on the other hand, some effective measures will be took to meet the ageing's demand for health care. In the future, the health ageing should be advocated, medical resources are optimized allocated to the ageing, meanwhile it will has more attention to the ageing in managed care, government's financial input, nursing insurance system, medical insurance system. It is the good way to meet the challenge from the ageing on health care system.
在我国,作为一个未富先老的人口大国,尤其在特有的城乡二元结构下,是否与通常认为随着老龄化程度的提高,医疗卫生支出会相应增长,这是值得探讨的一个重要问题。现有文献对这一问题的研究较少,且没有深入回答以下三个问题：在过去20年中,老龄化(尤其城乡老龄化)与医疗卫生支出的关系如何?老龄化影响医疗卫生支出的机制有哪些?在未来城乡融合趋势下,城乡老龄化对医疗卫生支出的影响趋势如何?为了回答上述问题,本文采用八个章节予以分析。首先从客观事实特征、文献综述出发梳理不同国家老龄化与医疗卫生支出的关系,厘清老龄化因素在医疗卫生支出中的作用以及影响机制。而后首次采用我国数据(宏观层面的省级面板数据(2002-2008年)和微观层面的CHNS混合截面数据(1991-2009年))从城乡差异的视角进行实证计量分析,以验证在我国现阶段城乡老龄化(年龄)是否是医疗卫生支出的决定因素?评估老龄化(年龄)因素在医疗卫生支出增长中的作用,探究老龄化(年龄)影响医疗卫生支出的机制等;并建立预测模型,在未来城乡融合的趋势下,对城乡老龄化进程下的医疗卫生支出趋势进行模拟预测。最后提出针对性的政策建议思考。
实证计量分析作为本文的主体内容以及创新性的体现,主要围绕医疗卫生支出中的门诊、住院支出进行分析,发现以下几点主要结论。
一是在总体上,上世纪90年代我国老龄人口的医疗卫生服务需求并没有得到有效满足,老龄化并没有推动医疗卫生支出增长,但在本世纪初开始老龄化与医疗卫生支出呈显著的正相关性,老龄化的医疗卫生支出弹性为0.278。另一方面,目前老龄化在医疗卫生支出增长中的影响程度有限,远低于收入、医疗技术。
二是现阶段城镇老龄人口的医疗卫生服务需求得到了一定程度的满足,推动了医疗卫生支出的增长(城镇老龄化的医疗卫生支出弹性为0.207)。在农村,由于经济发展水平较低、医疗保障体系不健全、医疗资源供给较为匮乏等原因导致老龄人口的医疗卫生服务需求并没有得到有效满足,因此,现阶段农村老龄化并没有影响医疗卫生支出,甚至随着老龄化程度的提高,其自费医疗卫生支出下降。
三是从年龄组的具体影响效应来看,城镇老龄组的患病概率、对医疗卫生支出的影响效应均大于农村老龄组。在生病且有医疗卫生支出的样本中,相比于城镇18-29岁年龄组,城镇60-69岁、70-79岁老龄组的医疗卫生支出分别增加了59.1%和76.4%,而农村却只分别增加了53.8%和55.1%。另一方面,健康状况显著影响年龄的具体影响效应,在城镇,一旦控制慢性病,老龄组对医疗卫生支出的影响效应将进一步增强.而农村却在减弱.某种程度表明,相比于农村,城镇患病老龄人口能得到有效的治疗,而农村可能存在有病不就医情况。
四是老龄化影响医疗卫生支出的机制主要通过医疗技术、医疗保险等资源向老龄人口倾斜,从而有效满足其医疗卫生服务需求。另一方面从微观个体来看,收入水平、健康状况会影响医疗卫生服务需求从而影响医疗卫生支出。对于农村来说,政府财政投入、收入水平、受教育程度提高将会极大增强老龄人口的医疗卫生服务需求满足程度。
五是从医疗卫生支出趋势来看.至2030年医疗卫生支出占GDP比重将达到8%-10.6%,至2050年将有40%的医疗资源配置于老龄人口。如果以城镇老龄化的医疗卫生服务需求满足程度为基准,农村老龄人口也得到同等程度的满足,则会使医疗卫生支出占GDP比重在2010-2030年间提高0.07-1.6个百分比。另一方面城乡老龄化进程的加快将促使医疗卫生支出占GDP比重上升,而放开人口政策、实施有效的医疗成本控制政策将有助于控制医疗卫生支出过快增长。
本文的政策含义主要有两方面。首先,基于未来城乡融合、城乡医疗服务差异缩小,农村老龄化将会推动医疗卫生支出快速增长,因此政策制定者在采取各项措施控制医疗卫生支出增长的同时,需要正视农村老龄人口医疗服务需求得到满足后医疗卫生支出增长的可能性。其次,虽然目前老龄化对医疗卫生支出的影响并不是很大,但是这并不意味着老龄化因素不重要,随着未来老龄化程度的加剧,对医疗卫生支出的影响将会日渐增大,未来将需要更多的医疗卫生资源向老龄人口(尤其农村老龄人口)倾斜。
正是基于此,未来需要充分把握我国人口结构变化特点,在采取有效措施控制医疗卫生支出快速增长的同时,又要有效满足老龄人口(尤其农村地区)的医疗卫生服务需求。具体来说,未来要提倡健康老龄化,加强各类医疗卫生资源有效配置力度,在健康管理、财政投入、护理保障体系、医疗保险体系等方面加强对老龄人口倾斜,从而及时有效应对老龄化对现有医疗卫生体制所产生的挑战。
The change of population structure and the rapid ageing process lead to the change of health care demand and health care expenditure and have been a big challenge for health care system. The ageing has a higher health depreciation rate and a stronger demand for health care, so health care expenditure will grow with the deepening of the ageing. However, some factors such as good economic conditions, adequate health care resource supply and so on have influence on the allocation of health care resource and the ageing's health care demand, so maybe health care expenditure will decline with the deepening of the aging. Therefore the relationship between the ageing and health care expenditure is obscure.
As a getting old before being rich developing country with a great population and urban-rural dual structure, whether ageing will lead to the growth of health care expenditure in our country is worthy of further discussion. Existing literatures have little attention on the relationship between ageing and health care expenditure and haven't answered the following three questions:what has been the real relationship between ageing and health care expenditure in the past20years, especially based on the urban-rural difference? How's the mechanism between ageing and health care expenditure? Will ageing accelerate health care expenditure in the future with the urban-rural composition? Eight chapters will be employed to answer the above-mentioned three questions in this study. Firstly, based on the objective facts and past literatures, we systematically review the relationship between ageing and health care expenditure in different countries, explore the mechanism between ageing and health care expenditure, analyse ageing's contribution to the growth of health care expenditure. Secondly, we use provincial panel data (2002-2008) at macro level and CHNS pooled cross-sectional data (1991-2009) at micro level to test whether ageing is one of the determinants of health care expenditure, estimate ageing's contribution, explore the mechanism between ageing and health care expenditure. Meanwhile, we set the simulation model to forecast the health care expenditure in the future. Finally, we put forward some corresponding suggestions.
Econometric analysis is the main content and innovative point. It targets outpatient and inpatient as some types of health care expenditure and its results are as followings.
First, the ageing's health care demand has not been met which has not accelerated health care expenditure in the late1990s. However, ageing has a positive relationship with the health care expenditure since the21st century. Ageing contribution to the growth of health care expenditure is limited, less than income, medical technology.
Second, from the urban-rural difference, the demand for urban ageing's health care has been met which drove up the health care expenditure. Meanwhile, in rural, ageing has little relationship with the health care expenditure because some factors such as a low economic development level, imperfect medical security system, scarce medical resource supply and so on can't meet the rural ageing's health care demand. Even the rural ageing has negative relationship with real per capita out-of-pocket health expenditure.
Third, more and more medical resource is allocated to the ageing by medical technology and medical insurance system which will meet the ageins's health care demand. On the other hand, from the micro individual level, income and health will impact the demand for health care and health care expenditure. In rural, income, education, government's financial input will make the ageing easier to obtain health care service.
Fourth, from the trend of health care expenditure, the ratio between health care expenditure and GDP will reach about8%-10.6%in2030,40percent of all medical resource will be allocated to the ageing in2050. If the rural ageing has the same satisfaction with the urban ageing in the demand for health care, the ratio between health care expenditure and GDP will enhance0.07-1.6percent. The rapid ageing process will accelerate the ratio between health care expenditure and GDP, however, the health care expenditure will be controlled by abandoning one-child policy and effective medical cost-control.
The policy meanings in this study are as followings. First, based on the urban-rural composition and decreasing gaps between urban and rural, the rural ageing will accelerate the rapid growth of health care expenditure, so the policy makers will take some effective measures to tackle the rapid growth of health care expenditure and have a proper recognition of the higher probability of the rapid growth of health care expenditure in rural. Second, ageing's contribution to the growth of health care expenditure is limited, but it will play a more important role in the growth of health care expenditure with the rapid ageing process. In the future, it needs more medical resource allocated to the ageing.
Based on the above-mentioned, we should have a good grasp of population structure trait. On one hand, some effective measures will be taken to tackle the rapid growth of health care expenditure, on the other hand, some effective measures will be took to meet the ageing's demand for health care. In the future, the health ageing should be advocated, medical resources are optimized allocated to the ageing, meanwhile it will has more attention to the ageing in managed care, government's financial input, nursing insurance system, medical insurance system. It is the good way to meet the challenge from the ageing on health care system.
引文
16年龄与健康投资之间的关系可参见封进(2009)。
17有关健康-风险效应与生命周期效应,更多地是指预防性医疗卫生服务,具体可见余央央(2011)。
44对老年人口的前期预防性医疗干预有助于提高老龄人口的健康(Schellhorn et al.,2000)。
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17有关健康-风险效应与生命周期效应,更多地是指预防性医疗卫生服务,具体可见余央央(2011)。
44对老年人口的前期预防性医疗干预有助于提高老龄人口的健康(Schellhorn et al.,2000)。
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