中国城镇健康需求和医疗保险改革研究
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摘要
医疗卫生改革是全球性的现象,是世界各国政府共同面对的难题,无论是以英国为代表的“全民健康服务”模式,还是以加拿大、澳大利亚为代表的“全民健康保险”模式,或是德国的分散化“社会保险”模式,或是新加坡的“强制储蓄”模式,抑或是美国的“商业医疗保险”模式,都在筹资、医疗服务提供以及运作管理等方面不同程度的暴露出亟待改进的问题。绝对成功的案例和理想的目标模式并不存在。
中国的医疗卫生体制也正处于改革的风口浪尖。2000年,世界卫生组织对191个会员国的卫生系统分三个方面进行了绩效评估,并发布了研究报告《2000年世界卫生报告——卫生系统：改进绩效》。报告中医疗卫生体系的排名,中国仅列第144位；在卫生负担公平性方面,中国被排列在第188位,即倒数第四位。“看病难、看病贵”已经成为社会生活中的突出矛盾,集中体现在医疗费用高速增长,医疗费用负担不公,低收入人群医疗服务可及性下降等。因此,医疗卫生体制改革在中国,是党和国家执政为民,维护社会、和谐稳定发展的当务之急。考察我国居民的健康需求和医疗保险体制也已成为经济学研究不可忽视的重大问题。
我国城镇在二十世纪五十年代直至改革开放之前,将免费医疗作为一种职工福利(劳保医疗)或国家福利(公费医疗)提供给特定的社会群体(企业职工及家属,国家机关和事业单位职工等)。随着“市场化”改革的不断推进,城镇传统的免费医疗体制受到冲击,医疗保障改革先是以广覆盖的社会保险代替单位职工福利式的劳保医疗,公费医疗随后也逐步向社会保险并轨。
随着实践问题的不断涌现和政策制定的迫切需要,健康和医疗卫生领域的研究,无论是理论上还是实证分析上都得到长足发展。同时,研究方法的完善,大型社会实验的开展以及数据的采集都为该领域的研究营造了良好环境。然而,医疗服务作为商品的特殊性,以及医疗服务市场的不确定性、信息不对称、外部性和垄断等特征为该领域的研究提出种种挑战。因此,如何正确评估我国的医疗保险体系,它对人们医疗服务消费和健康产生了怎样的影响；结合我国具体国情,我国的医疗保险是引致了过度的医疗支出还是释放了合理的医疗需求；城镇职工医疗保险改革取得怎样的社会效益,强化需求方费用意识的改革是否起到了控制医疗资源浪费、提高效率的目标；如何在医疗保险的框架下,从医疗服务和药品供给方的角度控制医疗支出、促进药物的合理利用。这一系列关系百姓切身利益的问题成为决策者和学者乃至民众关注的焦点。
本文的研究思路是,立足于中国医疗卫生体系,从影响居民健康和医疗消费行为的因素入手,借鉴国际上先进的医疗需求、政策评估以及价格成本分析方法,利用“中国老年人健康长寿影响因素调查数据(CLHLS)"、“中国健康与营养调查”和“工业企业统计报表”等微观数据围绕上述问题展开一系列的实证研究,为政策制定和改革路径的选择提供经验数据的支持。本文主要研究工作如下：
一、通过修正的样本选择模型,描述城镇公共医疗保险与人们医疗消费行为的关系
鉴于研究可得的数据的特殊性,常用于分析医疗支出的两部模型和样本选择模型并不适用,我们将样本选择模型根据实际数据加以扩展,首先考虑老人是否患病,进而选择是否就医,扩展的样本选择模型更具弹性,包容了健康老人真实医疗支出为零的情况。实证结果也双重验证了该模型的实用性。
通过对我国城镇老年人的医疗消费行为进行了深入的研究,本文发现医疗保险对总医疗支出有显著的正向影响的同时,显著地降低了自付医疗支出。享受医疗保险的老人,其家庭自付医疗支出则比无保险的老人低43%(约合1149元)；按照2005年已故和健在的老人的平均非零自付支出分别为3925元和2024元计算,享受保险的老人的年家庭自付医疗支出将分别减少1295元(33%)和951元(47%)。享受医疗保险的老人在过去一年中,总医疗支出比无保险的老人高28%-37%(约合1072元.1264元)。
二、基于生存分析和样本匹配方法,刻画医疗保险对健康的影响
无论采用离散时间风险模型还是连续时间生存分析,无论以生存状态还是生存持续时间作为被解释变量,在其他社会经济因素相同或相近的情况下,我们都发现享受医疗保险的城镇老年人具有明显的健康优势。我们采用倾向分数匹配的方法对样本选择性偏差加以修正,匹配样本的估计结果表明,享受医疗保险的老人,与无保险的老人相比,其死亡风险将减少17%.19%。
结合医疗支出方程和生存分析的结果,我们利用扩展的Kaplan-Meier生存函数计算了不同保险待遇的老人,按照生存概率加权的医疗支出的差异。给定老人生存至样本平均年龄,享受医疗保险的老人生存概率加权的平均总医疗支出为64689元,无医疗保险的老人的医疗支出为42198元,总医疗支出相差22491元,预期寿命相差5年。因此,享受医疗保险的城镇老年人,其医疗支出显著地有效地增进了健康状况。说明我国医疗卫生体制的主要矛盾是医疗服务需求因个人的经济能力受到抑制,应侧重于释放合理的医疗需求,扩大医疗保险的覆盖范围,便利民众医疗消费。
三、利用差分分析,考察城镇职工医疗保险改革的医疗支出效应和健康效应
利用CHNS调查数据提供的15年来的详尽微观信息,结合差分分析这一政策评估常用的工具,我们发现,1998年开始推行的城镇医疗保险改革在不损害改革对象的健康的前提下,一定程度上控制了医疗服务需求方的道德风险,抑制了不合理的医疗支出。从医疗资源配置的效率方面来看,个人帐户强化了医疗消费的自我责任,遏制了医疗资源浪费,挤出了不必要的过度需求。具体而言,改革后医保人群的总门诊支出相对与无保险人群减少了31.0%-33.5%,改革主要影响了人们医疗支出的幅度,而不是是否就医的决策。
医疗保险改革对住院医疗支出的报销比例较高,劳保及职工医疗和公费医疗的人群相对于无保险人群的住院医疗支出在改革前后并没有明显的变化。说明改革大病统筹、小病更多费用分担的保险安排,一定程度上减少医疗资源浪费,同时保障社会成员重大疾病风险的分散。医保人群门诊和住院的自付医疗支出和无保险人群相比,改革前后无显著差异。
从健康结果方面来看,根据面板数据Logit模型的分析结果,改革对职工健康状况没有负面的影响,医疗保险改革没有以牺牲社会成员的健康为代价。
四、借助医药制造业Lerner指数的估计,探索医疗保险框架下药品的政府定价问题
“看病难”、“看病贵”是我国当前突出的社会、经济、民生问题之一。老百姓的医疗支出主要由医疗服务价格和药品价格构成,我国的问题不是医疗服务价格过高,而是药品价格过高。仅从需求方入手,不对医疗服务和药品的供给方进行监管和控制,医疗费用仍会持续高涨。
为了控制医药费用不合理支出,保证药品的可及性,同时促进医药产业的健康发展,许多国家对药品价格实行广泛的干预和监管。我国政府对纳入《国家基本医疗保险药品目录》的药品价格实行政府指导价或政府定价。当然,对于医药市场结构和药品制造企业定价行为的客观研究和正确认识是政府有的放矢地实施干预的前提。经济学常用Lerner指数来度量市场垄断势力和定价行为,Lerner指数是价格与边际成本的差额占价格的比例,也就是单位价格中价格与边际成本的差额所占的比例,这一比例越高,表明企业市场垄断势力越大。而目前对于我国医药制造行业价格成本关系的研究较为缺乏。本文将在医疗保险的框架下,利用实证产业经济学的理论和实证方法,为我国政府有效实行药品价格监管提出有益的建议。
利用2003年-2007年我国医药制造企业微观数据,结合最新的生产函数估计方法,本文发现,我国医药制造企业Lerner (?)旨数约为0.521,表明平均每单位医药产品的销售额中,边际成本所占的比例仅占48%,而其余约52%为扣除边际成本的盈余。考察期内,我国医药制造业的Lerner指数不断下降,新企业进入导致医药制造业竞争加剧以及政府对药品价格实行管制导致了医药制造企业市场垄断势力的削弱。利用Harberger三角,我们计算了医药制造业不完全竞争导致的社会福利损失,在单位价格需求弹性的假设下,医药制造业福利损失约占行业总销售收入的14%。
本文可能的创新点主要体现在：
1.在研究内容上,通过我国医疗保险对医疗消费和健康的影响,我国医疗保险是引致了过度的医疗消费还是释放了合理的医疗需求,以及如何从社会效率的角度评价城镇职工医疗保险改革这三个内在逻辑上环环相扣的问题的探索,为我国医疗卫生改革政策进一步地调整和制定提供客观依据和参考。并首次在医疗保险的框架下,利用实证产业经济学的理论和方法,对医药市场结构和药品制造企业定价行为进行研究,为政府药品价格管制提出有益的建议。
2.在研究方法上,秉承实证精神,反复推敲逻辑和证据,大量运用经验分析对经济学理论及经济行为进行检验和预测,采用现代计量经济学和统计学的方法进行数据分析与建模手段,力求提供客观科学的评判,避免个人主观倾向。诺贝尔经济学奖得主Stigler(1965)预言经济学“即将步入其黄金时期”,因为“一个量化分析的时代正向我们全面走来”。在其看来,实证分析的发展是“一项头等重要的科学革命”,“一个理论通常可以用来支持多种不同的政策观点,理论揭示了一般性的关系,而实证证据则解决了特定背景下,理论的哪一部分起到决定作用的问题”。这一论断在医疗卫生领域得以实现,关于健康和医疗问题的数以千计的实证性文章为缩小各种观点的争议范围,调和各种政策差异起到了重要的作用。
除了运用公共经济学、健康经济学、保险经济学等一系列相关经济学科的研究范式外,还从多学科结合的研究视角,借鉴了社会学、人口学、老年学、政治伦理学和金融保险学的研究方法和成果。
3.在研究结论上,基于充分的结构性分析和经济主体行为刻画,提出我国医疗保险体系发展模式和方向,具有较强的实践指导意义。
综上所述,本文借鉴国际上前沿的健康经济学和实证产业组织理论和方法,以微观主体的健康需求为出发点,从医疗服务和医药产品的供、需双方入手,研究和评价我国城镇医疗保险发展和改革的一系列问题。本文的研究不仅丰富和更新了经济学相关领域的研究文献,并将有助于我国医疗卫生体制改革过程中各级政府和部门正确认识民众的健康需求和医疗消费行为以及医药制造企业的定价行为,科学合理地调整和制定政策,进一步发展和完善我国医疗保障体系,使民众安居乐业,社会安定和谐。因此,本文的研究具有重要的理论价值和社会意义。
Health and health care are fascinating subjects not just for health economists, but also for policymakers and the common people. Health care reforms worldwide try to make health care more affordable, expand coverage to all and make the health system sustainable. The reform of health insurance in urban China started three decades ago, which the mixture of social health insurance and medical saving accounts was introduced. It's important to track the changes of medical consumption behavior and health outcomes and evaluate the efficiency of the new system. Price of the pharmaceuticals is regulated by the government in most countries, including China. Direct measurement of price-cost margins would provide some further information which can be utilized in the decision-making concerning the price regulation of pharmaceuticals. The main purpose of this paper is to gain a better understanding of Chinese health care system on the basis of solid empirical evidence.
This paper applies the modern quantitative analysis method to investigate the relationship between health insurance and medical consumption behavior as well as health outcomes using household data. This paper presents the evaluation of Urban Employee Medical Insurance reform from the efficiency point of view. The study aslo examines the association between price and marginal cost in pharmaceutical industry and investigate the empirical evidence from firm-level data. The major findings are as follow:
1. Estimating the effects of Public Health Insurance on medical expenditure with modified sample selection model.
We examine the impacts of public health insurance on total and out-of-pocket medical expenditures among elderly in urban China. Using the latest waves of Chinese Longitudinal Healthy Longevity Survey (CLHLS), we find that the out-of-pocket medical expenditures of insured elderly are 43 percent lower than that of the uninsured elderly; but the total medical expenditures are 28-37 percent higher compared to uninsured.
2. Measuring the impacts of Pubic Health Insurance on mortality with survival analysis and propensity score matching method.
We address the question of how health insurance affects health. I find significant reduction in all cause mortality associated with health insurance. Based on Cox proportional hazard model, the insured elderly face a hazard 19% lower than the uninsured. According to extended Kaplan-Meier survival curve, the extended mean survival time of the insured elderly is 154 months and is noticeably larger than mean of uninsured,94 months. Those finding suggest that increased medical expenditures significantly and effectively improved the health and longevity of the insured old people. Therefore, the public health insurance policy should make more effort to meet the reasonable medical care demand.
3. Evaluating the Urban Employee Medical Insurance reform from the efficiency point of view with difference-in-difference model.
We use individual-level medical expenditure data from Chinese Health and Nutrition Survey (CHNS) to study the effects of the health insurance reform in urban China, i.e. the Urban Employment Medical Insurance (UEMI). Using the sample selection model and the difference-in-difference estimator where the uninsured people serve as the control group, we find that:the health insurance reform substantially reduces the moral hazard problem. After the reform, people with UEMI would not change their probabilities of seeing doctors but decrease the outpatient expenses by 31.0-33.5 percent. There is no statistically significant change for inpatient expenditure. Out-of-pocket expenses for both inpatient care and outpatient care do not vary with the reform. Further, the reform did not significantly change the probability of being sick. Therefore, this paper concludes that the UEMI reform reduce the unreasonable medical expenditure by incorporating the demand side incentive.
4. Analyzing the Lerner Index of pharmaceutical industry for drug price regulation under the framework of basic health insurance
To provide some insights for drug price regulation, we estimate the price-cost margin in the China pharmaceutical industry. Using the survey data of Large and Medium size enterprises that China's National Bureau of Statistics (NBS) conducts every year, the estimated Lerner Index in the pharmaceutical industry is 0.521 and statistically significant, which means of the total value added per unit sales, only 48 percent is marginal cost; the rest is earnings from market power. The total welfare loss due to imperfect competition is about 14% of revenues.
This applied study on social health insurance in urban China has both theoretic and pratical significant from the following aspects:it will amples and updates the related literature on Chinese health insurance reform; it will foster the better understanding of demand of health and health care and production of health as well as pricng behavior of pharmaceutical industry; it can be utilized in the decision-making concerning the public health policy, such as health insurance reform and price regulation of pharmaceuticals.
中国的医疗卫生体制也正处于改革的风口浪尖。2000年,世界卫生组织对191个会员国的卫生系统分三个方面进行了绩效评估,并发布了研究报告《2000年世界卫生报告——卫生系统：改进绩效》。报告中医疗卫生体系的排名,中国仅列第144位；在卫生负担公平性方面,中国被排列在第188位,即倒数第四位。“看病难、看病贵”已经成为社会生活中的突出矛盾,集中体现在医疗费用高速增长,医疗费用负担不公,低收入人群医疗服务可及性下降等。因此,医疗卫生体制改革在中国,是党和国家执政为民,维护社会、和谐稳定发展的当务之急。考察我国居民的健康需求和医疗保险体制也已成为经济学研究不可忽视的重大问题。
我国城镇在二十世纪五十年代直至改革开放之前,将免费医疗作为一种职工福利(劳保医疗)或国家福利(公费医疗)提供给特定的社会群体(企业职工及家属,国家机关和事业单位职工等)。随着“市场化”改革的不断推进,城镇传统的免费医疗体制受到冲击,医疗保障改革先是以广覆盖的社会保险代替单位职工福利式的劳保医疗,公费医疗随后也逐步向社会保险并轨。
随着实践问题的不断涌现和政策制定的迫切需要,健康和医疗卫生领域的研究,无论是理论上还是实证分析上都得到长足发展。同时,研究方法的完善,大型社会实验的开展以及数据的采集都为该领域的研究营造了良好环境。然而,医疗服务作为商品的特殊性,以及医疗服务市场的不确定性、信息不对称、外部性和垄断等特征为该领域的研究提出种种挑战。因此,如何正确评估我国的医疗保险体系,它对人们医疗服务消费和健康产生了怎样的影响；结合我国具体国情,我国的医疗保险是引致了过度的医疗支出还是释放了合理的医疗需求；城镇职工医疗保险改革取得怎样的社会效益,强化需求方费用意识的改革是否起到了控制医疗资源浪费、提高效率的目标；如何在医疗保险的框架下,从医疗服务和药品供给方的角度控制医疗支出、促进药物的合理利用。这一系列关系百姓切身利益的问题成为决策者和学者乃至民众关注的焦点。
本文的研究思路是,立足于中国医疗卫生体系,从影响居民健康和医疗消费行为的因素入手,借鉴国际上先进的医疗需求、政策评估以及价格成本分析方法,利用“中国老年人健康长寿影响因素调查数据(CLHLS)"、“中国健康与营养调查”和“工业企业统计报表”等微观数据围绕上述问题展开一系列的实证研究,为政策制定和改革路径的选择提供经验数据的支持。本文主要研究工作如下：
一、通过修正的样本选择模型,描述城镇公共医疗保险与人们医疗消费行为的关系
鉴于研究可得的数据的特殊性,常用于分析医疗支出的两部模型和样本选择模型并不适用,我们将样本选择模型根据实际数据加以扩展,首先考虑老人是否患病,进而选择是否就医,扩展的样本选择模型更具弹性,包容了健康老人真实医疗支出为零的情况。实证结果也双重验证了该模型的实用性。
通过对我国城镇老年人的医疗消费行为进行了深入的研究,本文发现医疗保险对总医疗支出有显著的正向影响的同时,显著地降低了自付医疗支出。享受医疗保险的老人,其家庭自付医疗支出则比无保险的老人低43%(约合1149元)；按照2005年已故和健在的老人的平均非零自付支出分别为3925元和2024元计算,享受保险的老人的年家庭自付医疗支出将分别减少1295元(33%)和951元(47%)。享受医疗保险的老人在过去一年中,总医疗支出比无保险的老人高28%-37%(约合1072元.1264元)。
二、基于生存分析和样本匹配方法,刻画医疗保险对健康的影响
无论采用离散时间风险模型还是连续时间生存分析,无论以生存状态还是生存持续时间作为被解释变量,在其他社会经济因素相同或相近的情况下,我们都发现享受医疗保险的城镇老年人具有明显的健康优势。我们采用倾向分数匹配的方法对样本选择性偏差加以修正,匹配样本的估计结果表明,享受医疗保险的老人,与无保险的老人相比,其死亡风险将减少17%.19%。
结合医疗支出方程和生存分析的结果,我们利用扩展的Kaplan-Meier生存函数计算了不同保险待遇的老人,按照生存概率加权的医疗支出的差异。给定老人生存至样本平均年龄,享受医疗保险的老人生存概率加权的平均总医疗支出为64689元,无医疗保险的老人的医疗支出为42198元,总医疗支出相差22491元,预期寿命相差5年。因此,享受医疗保险的城镇老年人,其医疗支出显著地有效地增进了健康状况。说明我国医疗卫生体制的主要矛盾是医疗服务需求因个人的经济能力受到抑制,应侧重于释放合理的医疗需求,扩大医疗保险的覆盖范围,便利民众医疗消费。
三、利用差分分析,考察城镇职工医疗保险改革的医疗支出效应和健康效应
利用CHNS调查数据提供的15年来的详尽微观信息,结合差分分析这一政策评估常用的工具,我们发现,1998年开始推行的城镇医疗保险改革在不损害改革对象的健康的前提下,一定程度上控制了医疗服务需求方的道德风险,抑制了不合理的医疗支出。从医疗资源配置的效率方面来看,个人帐户强化了医疗消费的自我责任,遏制了医疗资源浪费,挤出了不必要的过度需求。具体而言,改革后医保人群的总门诊支出相对与无保险人群减少了31.0%-33.5%,改革主要影响了人们医疗支出的幅度,而不是是否就医的决策。
医疗保险改革对住院医疗支出的报销比例较高,劳保及职工医疗和公费医疗的人群相对于无保险人群的住院医疗支出在改革前后并没有明显的变化。说明改革大病统筹、小病更多费用分担的保险安排,一定程度上减少医疗资源浪费,同时保障社会成员重大疾病风险的分散。医保人群门诊和住院的自付医疗支出和无保险人群相比,改革前后无显著差异。
从健康结果方面来看,根据面板数据Logit模型的分析结果,改革对职工健康状况没有负面的影响,医疗保险改革没有以牺牲社会成员的健康为代价。
四、借助医药制造业Lerner指数的估计,探索医疗保险框架下药品的政府定价问题
“看病难”、“看病贵”是我国当前突出的社会、经济、民生问题之一。老百姓的医疗支出主要由医疗服务价格和药品价格构成,我国的问题不是医疗服务价格过高,而是药品价格过高。仅从需求方入手,不对医疗服务和药品的供给方进行监管和控制,医疗费用仍会持续高涨。
为了控制医药费用不合理支出,保证药品的可及性,同时促进医药产业的健康发展,许多国家对药品价格实行广泛的干预和监管。我国政府对纳入《国家基本医疗保险药品目录》的药品价格实行政府指导价或政府定价。当然,对于医药市场结构和药品制造企业定价行为的客观研究和正确认识是政府有的放矢地实施干预的前提。经济学常用Lerner指数来度量市场垄断势力和定价行为,Lerner指数是价格与边际成本的差额占价格的比例,也就是单位价格中价格与边际成本的差额所占的比例,这一比例越高,表明企业市场垄断势力越大。而目前对于我国医药制造行业价格成本关系的研究较为缺乏。本文将在医疗保险的框架下,利用实证产业经济学的理论和实证方法,为我国政府有效实行药品价格监管提出有益的建议。
利用2003年-2007年我国医药制造企业微观数据,结合最新的生产函数估计方法,本文发现,我国医药制造企业Lerner (?)旨数约为0.521,表明平均每单位医药产品的销售额中,边际成本所占的比例仅占48%,而其余约52%为扣除边际成本的盈余。考察期内,我国医药制造业的Lerner指数不断下降,新企业进入导致医药制造业竞争加剧以及政府对药品价格实行管制导致了医药制造企业市场垄断势力的削弱。利用Harberger三角,我们计算了医药制造业不完全竞争导致的社会福利损失,在单位价格需求弹性的假设下,医药制造业福利损失约占行业总销售收入的14%。
本文可能的创新点主要体现在：
1.在研究内容上,通过我国医疗保险对医疗消费和健康的影响,我国医疗保险是引致了过度的医疗消费还是释放了合理的医疗需求,以及如何从社会效率的角度评价城镇职工医疗保险改革这三个内在逻辑上环环相扣的问题的探索,为我国医疗卫生改革政策进一步地调整和制定提供客观依据和参考。并首次在医疗保险的框架下,利用实证产业经济学的理论和方法,对医药市场结构和药品制造企业定价行为进行研究,为政府药品价格管制提出有益的建议。
2.在研究方法上,秉承实证精神,反复推敲逻辑和证据,大量运用经验分析对经济学理论及经济行为进行检验和预测,采用现代计量经济学和统计学的方法进行数据分析与建模手段,力求提供客观科学的评判,避免个人主观倾向。诺贝尔经济学奖得主Stigler(1965)预言经济学“即将步入其黄金时期”,因为“一个量化分析的时代正向我们全面走来”。在其看来,实证分析的发展是“一项头等重要的科学革命”,“一个理论通常可以用来支持多种不同的政策观点,理论揭示了一般性的关系,而实证证据则解决了特定背景下,理论的哪一部分起到决定作用的问题”。这一论断在医疗卫生领域得以实现,关于健康和医疗问题的数以千计的实证性文章为缩小各种观点的争议范围,调和各种政策差异起到了重要的作用。
除了运用公共经济学、健康经济学、保险经济学等一系列相关经济学科的研究范式外,还从多学科结合的研究视角,借鉴了社会学、人口学、老年学、政治伦理学和金融保险学的研究方法和成果。
3.在研究结论上,基于充分的结构性分析和经济主体行为刻画,提出我国医疗保险体系发展模式和方向,具有较强的实践指导意义。
综上所述,本文借鉴国际上前沿的健康经济学和实证产业组织理论和方法,以微观主体的健康需求为出发点,从医疗服务和医药产品的供、需双方入手,研究和评价我国城镇医疗保险发展和改革的一系列问题。本文的研究不仅丰富和更新了经济学相关领域的研究文献,并将有助于我国医疗卫生体制改革过程中各级政府和部门正确认识民众的健康需求和医疗消费行为以及医药制造企业的定价行为,科学合理地调整和制定政策,进一步发展和完善我国医疗保障体系,使民众安居乐业,社会安定和谐。因此,本文的研究具有重要的理论价值和社会意义。
Health and health care are fascinating subjects not just for health economists, but also for policymakers and the common people. Health care reforms worldwide try to make health care more affordable, expand coverage to all and make the health system sustainable. The reform of health insurance in urban China started three decades ago, which the mixture of social health insurance and medical saving accounts was introduced. It's important to track the changes of medical consumption behavior and health outcomes and evaluate the efficiency of the new system. Price of the pharmaceuticals is regulated by the government in most countries, including China. Direct measurement of price-cost margins would provide some further information which can be utilized in the decision-making concerning the price regulation of pharmaceuticals. The main purpose of this paper is to gain a better understanding of Chinese health care system on the basis of solid empirical evidence.
This paper applies the modern quantitative analysis method to investigate the relationship between health insurance and medical consumption behavior as well as health outcomes using household data. This paper presents the evaluation of Urban Employee Medical Insurance reform from the efficiency point of view. The study aslo examines the association between price and marginal cost in pharmaceutical industry and investigate the empirical evidence from firm-level data. The major findings are as follow:
1. Estimating the effects of Public Health Insurance on medical expenditure with modified sample selection model.
We examine the impacts of public health insurance on total and out-of-pocket medical expenditures among elderly in urban China. Using the latest waves of Chinese Longitudinal Healthy Longevity Survey (CLHLS), we find that the out-of-pocket medical expenditures of insured elderly are 43 percent lower than that of the uninsured elderly; but the total medical expenditures are 28-37 percent higher compared to uninsured.
2. Measuring the impacts of Pubic Health Insurance on mortality with survival analysis and propensity score matching method.
We address the question of how health insurance affects health. I find significant reduction in all cause mortality associated with health insurance. Based on Cox proportional hazard model, the insured elderly face a hazard 19% lower than the uninsured. According to extended Kaplan-Meier survival curve, the extended mean survival time of the insured elderly is 154 months and is noticeably larger than mean of uninsured,94 months. Those finding suggest that increased medical expenditures significantly and effectively improved the health and longevity of the insured old people. Therefore, the public health insurance policy should make more effort to meet the reasonable medical care demand.
3. Evaluating the Urban Employee Medical Insurance reform from the efficiency point of view with difference-in-difference model.
We use individual-level medical expenditure data from Chinese Health and Nutrition Survey (CHNS) to study the effects of the health insurance reform in urban China, i.e. the Urban Employment Medical Insurance (UEMI). Using the sample selection model and the difference-in-difference estimator where the uninsured people serve as the control group, we find that:the health insurance reform substantially reduces the moral hazard problem. After the reform, people with UEMI would not change their probabilities of seeing doctors but decrease the outpatient expenses by 31.0-33.5 percent. There is no statistically significant change for inpatient expenditure. Out-of-pocket expenses for both inpatient care and outpatient care do not vary with the reform. Further, the reform did not significantly change the probability of being sick. Therefore, this paper concludes that the UEMI reform reduce the unreasonable medical expenditure by incorporating the demand side incentive.
4. Analyzing the Lerner Index of pharmaceutical industry for drug price regulation under the framework of basic health insurance
To provide some insights for drug price regulation, we estimate the price-cost margin in the China pharmaceutical industry. Using the survey data of Large and Medium size enterprises that China's National Bureau of Statistics (NBS) conducts every year, the estimated Lerner Index in the pharmaceutical industry is 0.521 and statistically significant, which means of the total value added per unit sales, only 48 percent is marginal cost; the rest is earnings from market power. The total welfare loss due to imperfect competition is about 14% of revenues.
This applied study on social health insurance in urban China has both theoretic and pratical significant from the following aspects:it will amples and updates the related literature on Chinese health insurance reform; it will foster the better understanding of demand of health and health care and production of health as well as pricng behavior of pharmaceutical industry; it can be utilized in the decision-making concerning the public health policy, such as health insurance reform and price regulation of pharmaceuticals.
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1.陈启鸿,2000：《门诊医疗服务与基本医疗保险基金的个人账户》,《卫生软科学》第1期：14-16。
2.邓大松,2004：《基本医疗保险对退休老人保障效果分析》,《当代财经》第2期：28-31。
3.董维真,2004：《上海市医保筹资制度改革建议》,《中国卫生经济》第8期：27.29。
4.葛延风,王晓明,贡森等,2005：《对中国医疗卫生体制改革的评价和建议》,国务院发展研究中心课题组。
5.顾听,2005：《中国城市医疗体制的转型》,《比较》,第19辑
6.郭静,王鸿勇,2006：《日本医疗保险制度改革的借鉴》,《<国外医学>卫生经济分册》,第23卷第一期
7.国务院发展研究中心课题组,2005,对中国医疗卫生体制改革的评价和建议。
8.姜向群,万红霞.老年人口的医疗需求和医疗保险制度改革[J].《中国人口科学》,2004,(S1)
9.李国鸿,2005：《加拿大医疗保险改革研究》,《<国外医学>卫生经济分册》,第22卷第二期
10.李国鸿,2008：《加拿大医疗服务体系研究与启示》,《<国外医学>卫生经济分册》,第25卷第一期
11.林枫,2004：《从医疗保险基金筹集和收支看医保的共济能力》,《中国卫生经济》第2期：44.47。
12.刘国恩,蔡仁华,熊先军,赵忠云,2003：《中国城市医疗保险体制改革：论成本分担的公平性》,《经济学季刊》第2期。
13.刘国恩,董朝晖,孟庆勋,阎丽静,2006：《医疗保险个人账户的功能与影响(综述)》,《中国卫生经济》第2期。
14.罗楚亮.城镇居民健康差异与医疗支出行为[J].《财经研究》,2008年10月
15.孟庆跃,成刚,孙小杰,2004：《药品价格政策对药品费用控制的影响研究》,《中国卫生经济》第4期
16.王红玲,2002：《中国城镇居民医疗需求的实证分析》,《数量经济技术经济研究》第7期。
17.魏聪,2005：《医生行为的经济学——一个引致需求视角的文献综述》,《浙江社会科学》第2期。
18.魏众,B1古斯塔夫森,2005：《中国居民医疗支出不公平性分析》,《经济研究》第12期。
19.吴志澄,2003：《中国城镇化进程中的居民医疗保健需求研究》,《数量经济技术经济研究》第11期。
20.谢垩.与收入相关的健康及医疗服务利用不平等研究[J].《经济研究》,2009年第2期。
21.薛新东,赵曼,2008：《供给诱导需求研究综述》,《医学与哲学(人文社会医学版)》第2期。
22.约翰·亚伯拉罕,2001：《渐进式变迁——美英两国药品政府规制的百年演进》,《北大法律评论》第2期
23.曾毅,柳玉芝,萧振禹,张纯元.中国高龄老人的社会经济与健康状况[J].《中国人口科学》,2004,(S1)
24.章剑峰,2006,：《中国药价真相调查》,《财经文摘》第11期
25.赵忠,侯振刚.我国城镇居民的健康需求与Grossman模型[J].《经济研究》,2005年第10期
26.郑国强,1997：《职工医疗保障制度改革试点的回顾》,《卫生经济研究》第4期：27.28。
27.郑伟一,2004：《从医疗费用情况看完善支付机制的重要性》,《中国卫生经济》第2期：48.50。
28.周云,2006：《中国城市医疗保障制度重构研究》,武汉大学博士论文,2006。
29.朱恒鹏,2007：《医疗体制弊端与药品定价扭曲》,《中国社会科学》第4期
30.左学金,胡苏云,2001：《城镇医疗保险制度改革：政府与市场的作用》,《中国社会科学》第5期。
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1.陈启鸿,2000：《门诊医疗服务与基本医疗保险基金的个人账户》,《卫生软科学》第1期：14-16。
2.邓大松,2004：《基本医疗保险对退休老人保障效果分析》,《当代财经》第2期：28-31。
3.董维真,2004：《上海市医保筹资制度改革建议》,《中国卫生经济》第8期：27.29。
4.葛延风,王晓明,贡森等,2005：《对中国医疗卫生体制改革的评价和建议》,国务院发展研究中心课题组。
5.顾听,2005：《中国城市医疗体制的转型》,《比较》,第19辑
6.郭静,王鸿勇,2006：《日本医疗保险制度改革的借鉴》,《<国外医学>卫生经济分册》,第23卷第一期
7.国务院发展研究中心课题组,2005,对中国医疗卫生体制改革的评价和建议。
8.姜向群,万红霞.老年人口的医疗需求和医疗保险制度改革[J].《中国人口科学》,2004,(S1)
9.李国鸿,2005：《加拿大医疗保险改革研究》,《<国外医学>卫生经济分册》,第22卷第二期
10.李国鸿,2008：《加拿大医疗服务体系研究与启示》,《<国外医学>卫生经济分册》,第25卷第一期
11.林枫,2004：《从医疗保险基金筹集和收支看医保的共济能力》,《中国卫生经济》第2期：44.47。
12.刘国恩,蔡仁华,熊先军,赵忠云,2003：《中国城市医疗保险体制改革：论成本分担的公平性》,《经济学季刊》第2期。
13.刘国恩,董朝晖,孟庆勋,阎丽静,2006：《医疗保险个人账户的功能与影响(综述)》,《中国卫生经济》第2期。
14.罗楚亮.城镇居民健康差异与医疗支出行为[J].《财经研究》,2008年10月
15.孟庆跃,成刚,孙小杰,2004：《药品价格政策对药品费用控制的影响研究》,《中国卫生经济》第4期
16.王红玲,2002：《中国城镇居民医疗需求的实证分析》,《数量经济技术经济研究》第7期。
17.魏聪,2005：《医生行为的经济学——一个引致需求视角的文献综述》,《浙江社会科学》第2期。
18.魏众,B1古斯塔夫森,2005：《中国居民医疗支出不公平性分析》,《经济研究》第12期。
19.吴志澄,2003：《中国城镇化进程中的居民医疗保健需求研究》,《数量经济技术经济研究》第11期。
20.谢垩.与收入相关的健康及医疗服务利用不平等研究[J].《经济研究》,2009年第2期。
21.薛新东,赵曼,2008：《供给诱导需求研究综述》,《医学与哲学(人文社会医学版)》第2期。
22.约翰·亚伯拉罕,2001：《渐进式变迁——美英两国药品政府规制的百年演进》,《北大法律评论》第2期
23.曾毅,柳玉芝,萧振禹,张纯元.中国高龄老人的社会经济与健康状况[J].《中国人口科学》,2004,(S1)
24.章剑峰,2006,：《中国药价真相调查》,《财经文摘》第11期
25.赵忠,侯振刚.我国城镇居民的健康需求与Grossman模型[J].《经济研究》,2005年第10期
26.郑国强,1997：《职工医疗保障制度改革试点的回顾》,《卫生经济研究》第4期：27.28。
27.郑伟一,2004：《从医疗费用情况看完善支付机制的重要性》,《中国卫生经济》第2期：48.50。
28.周云,2006：《中国城市医疗保障制度重构研究》,武汉大学博士论文,2006。
29.朱恒鹏,2007：《医疗体制弊端与药品定价扭曲》,《中国社会科学》第4期
30.左学金,胡苏云,2001：《城镇医疗保险制度改革：政府与市场的作用》,《中国社会科学》第5期。