医疗保险与医疗支付行为的经验研究
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摘要
文章利用“中国居民家庭收入调查”(CHIPs)1995和2002年的城镇住户调查数据,首先运用双差分方法(difference-in-differences)从性别角度考察医疗保险政策的效果,研究发现医疗保险缩小了医疗费用支付的性别差异,但是女性的支付弹性高于男性,具有较高的支付风险,而医疗保险的覆盖使男性的获益优于女性。文章还从反事实分析框架出发,讨论了医保参与以及医疗保险中的道德风险和过度使用情况。文章采用倾向性得分匹配(PSM)估计法有效地控制了样本自选择问题。研究结果表明,1995年的医疗保障体系中存在被保险者的道德风险威胁,较高比例的公费医疗使得医疗资源利用低下,配置不公平;2002年的医疗保险安排,虽然不存在严重的道德风险威胁,但却出现了医疗服务过度使用的情况。
The paper investigates the relationship between health care insurance and expenditures in urban China. Using the two waves of Chinese Household Income Project Survey (CHIPs), we find that under different types of medical care insurance people’s behaviors on expenditures tend to be varied. From a gender perspective, we evaluate the effect of health care insurance and find that the health care insurance reduced the gender gap on medical expenses and provided male more benefits than female. Due to the self-selection problems associated with non-experimental data, we implement Propensity Score Matching (PSM) methods to measure the possibilities of insurance enrollment. The results show that there are moral hazard problems in 1995 health insurance system. Higher proportion of public health insurance led lower levels in utilization of medical resources. In 2002, medical insurance system effectively improved people’s abilities of medical payments. Over-Utilization in medical services, however, existed in all types of medical care insurance, especially free medical services.
The paper investigates the relationship between health care insurance and expenditures in urban China. Using the two waves of Chinese Household Income Project Survey (CHIPs), we find that under different types of medical care insurance people’s behaviors on expenditures tend to be varied. From a gender perspective, we evaluate the effect of health care insurance and find that the health care insurance reduced the gender gap on medical expenses and provided male more benefits than female. Due to the self-selection problems associated with non-experimental data, we implement Propensity Score Matching (PSM) methods to measure the possibilities of insurance enrollment. The results show that there are moral hazard problems in 1995 health insurance system. Higher proportion of public health insurance led lower levels in utilization of medical resources. In 2002, medical insurance system effectively improved people’s abilities of medical payments. Over-Utilization in medical services, however, existed in all types of medical care insurance, especially free medical services.
引文
Adam Wagstaff, and Menno Pradhan,“Health Insurance Impacts on Health and Nonmedical Consumption in a Developing Country”,World Bank Policy Research Working Paper,2005.
Antonio Trujillo, Jorge Portillo and John Vernon,“The Impact of Subsidized Health Insurance for the Poor: Evaluating the Colombian Experience Using Propensity Score Matching”,International Journal of Health Care Finance and Economics,5(3),2005.
Abadie, Alberto, David Drukker, Jane L. Herr and Guido W. Imbens,“Implementing Matching Estimators for Average Treatment Effects in Stata”, The Stata Journal 1, 2001.
Claudio Sapelli, & Bernardita Vial,“Self-selection and moral hazard in Chilean health insurance”, Journal of Health Economics, 22, 2003.
Duflo, Esther,“Schooling and Labor Market Consequences of School Construction in Indonesia: Evidence from an Unusual Policy Experiment,”The American Economic Review, 91:4, 2001.
Gerdtham,“The impact of aging on health care expenditure in Sweden”, Health Policy, Vol.24, 1993.
Hong Li Wang, Winnie Yip, Licheng Zhang and William C. Hsiao,“The impact of rural mutual health care on health status: evaluation of a social experiment in rural China”, Health Economics, vol.18, issue S2, 2009.
Imbens and Wooldridge,“Difference-in-Differences Estimation,Lecture Notes 10, Summer’07”,NBER, 2007.
Jere R. Behrman and Anil B. Deolalikar,“The Intrahousehold Demand for Nutrients in Rural South India: Individual Estimates, Fixed Effects, and Permanent Income”,The Journal of Human Resources, Vol. 25, No. 4 (Autumn, 1990), pp. 665-696.
Leuven, Edwin and Barbara Sianesi,“Psmatch2: Stata Module to perform full Mahalanobis and Propensity Score Matching, Common Support Graphing, and Covariate Imbalance Testing, http://ideas.repec.org/c/boc/bocode/s43200 1.html, version 3.0.0. (Date visited: August 16, 2010) 2003.
Liu Y, Rao K, Hsiao WC.,“Medical Expenditure and Rural Impoverishment in China”, Journal of Health, Population and Nutrition, 21, 2003.
Liu Y.,“Development of the rural health insurance system in China”, Health Policy Plan,19,2004.
Liu Yuanli,“Reforming China’s urban health insurance system”,Health Policy(60):2002.
Lina Song,“In Search of Gender Bias in Household Resource Allocation in Rural China”,IZA Discussion Paper No. 3464. Institute for the Study of Labor (IZA), 2008.
Ling Xu, Yan Wang, Charles D Collins and Shenglan Tang,“Urban health insurance reform and coverage in China using data from National Health Services Surveys in 1998 and 2003”, BMC Health Services Research ,2007.
Mariacristina De Nardi, Eric French, and John Bailey Jones,“Differential Mortality, Uncertain Medical Expenses, and the Saving of Elderly Singles”, NBER Working Paper ,http://bank-banque-canada.ca/en/conference_papers/workshop_may2007/denardi.pdf,2006.
Mengtao Gao and Yang Yao,“Gender Gaps in Access to Health Care in Rural China”,Economic Development and Cultural Change, 55:87–107,2006.
Newhouse,“Medical care costs: how much welfare loss?”, Journal of Economic Perspective, 6, 1992.
Newhouse,“Free for All? Lessons from the RAND Health Insurance Experiment”, Harvard University Press, 1993.
Ramesh Subramaniam,“Gender-Bias in India: The Importance of Household Fixed-Effects”, Oxford Economic Papers, New Series, Vol. 48, No. 2 (Apr., 1996).
Sascha O. Becker,Andrea Ichino,“Estimation of average treatment effects based on propensity scores”, The Stata Journal, 2(4), 2002.
Shin-Yi Chou, Jin-Tan Liu, and James K. Hammitt,“National Health Insurance and precautionary saving:evidence from Taiwan”, Journal of Public Economics 87: 2003.
Smith, Jeffery A., & Petra Todd ,“Does Matching Overcome LaLonde’s Critique of Nonexperimental Estimators?”, Journal of Econometrics, 125, 2005.
陈佳贵主编:《中国社会保障发展报告(1997-2001)》,社会科学文献出版社2001年版。
国务院:《关于建立城镇职工基本医疗保险制度的决定》,http://www.gov.cn/banshi/2005-08/ 04/content_20256.htm,2010年12月17日14点09分。
国务院:《中共中央国务院关于深化医药卫生体制改革的意见》, http://www.gov.cn/jrzg/ 2009-04/06/content_1278721.htm,2010年12月17日14点11分。
郭有德:《医疗费用上涨原因及控制对策研究》,《中国卫生资源》2005年第8卷第3期。
黄枫、甘犁:《过度需求还是有效需求:城镇老人健康与医疗保险的实证分析》,《经济研究》,2010年第6期。
劳动和社会保障部:《关于1992年劳动事业发展的公报》,《中国劳动》1993年第7期。
劳动和社会保障部:《关于1993年劳动事业发展的公报》,http://www.gsjsw.gov.cn/html/ dczltjsj/11_36_18_616.html,2010年3月5日10点18分。
罗楚亮:《城镇居民健康差异与医疗支出行为》,《财经研究》2008年第10期。
罗楚亮、熊晓曦:《新医改可否解决医疗费用上涨之惑》,《西部论丛》2009年第5期。
谢垩:《与收入相关的健康及医疗服务利用不平等研究》,《经济研究》2009年第2期。
俞炳匡:《医疗改革的经济学》,中信出版社2008年版。
宋晓梧、刘浩:“医疗保险制度改革及配套措施”,《中国社会保障体制改革与发展报告》(宋晓梧主笔),中国人民大学出版社2001年版。
宋晓梧:《中国社会保障制度改革》,清华大学出版社2000年版。
宋丽娜:“中国农村家庭资源配置的性别效应”,《中国居民收入分配再研究》,中国财政经济出版社1999年版。
吴要武、赵泉:《高校扩招与大学毕业生就业》,《经济研究》第9期。
卫生部:《1997-2001年我国卫生事业发展情况简报》,http://www.moh.gov.cn/publicfiles/ business/htmlfiles/zwgkzt/pgb/200805/34846.htm,2011年3月3日15点41分。
卫生部:《2008年我国卫生改革与发展情况》,http://www.moh.gov.cn/publicfiles/business/ htmlfiles/mohbgt/s6690/200902/39109.htm,2011年3月3日15点41分。
朱文轶、李菁、王鸿谅、吴琪:《封面故事:垄断的大医院》,《三联生活周刊》总349期,2005年8月22日。
郑秉文、高庆波、于环:“新中国社会保障制度的变迁与发展”,《社会保障绿皮书:中国社会保障发展报告2010,No.4》(陈佳贵、王延中主编),社科文献出版社2010年版。
周亚虹、许玲丽、夏正青,《从农村职业教育看人力资本对农村家庭的贡献》,《经济研究》2010年第8期。
Antonio Trujillo, Jorge Portillo and John Vernon,“The Impact of Subsidized Health Insurance for the Poor: Evaluating the Colombian Experience Using Propensity Score Matching”,International Journal of Health Care Finance and Economics,5(3),2005.
Abadie, Alberto, David Drukker, Jane L. Herr and Guido W. Imbens,“Implementing Matching Estimators for Average Treatment Effects in Stata”, The Stata Journal 1, 2001.
Claudio Sapelli, & Bernardita Vial,“Self-selection and moral hazard in Chilean health insurance”, Journal of Health Economics, 22, 2003.
Duflo, Esther,“Schooling and Labor Market Consequences of School Construction in Indonesia: Evidence from an Unusual Policy Experiment,”The American Economic Review, 91:4, 2001.
Gerdtham,“The impact of aging on health care expenditure in Sweden”, Health Policy, Vol.24, 1993.
Hong Li Wang, Winnie Yip, Licheng Zhang and William C. Hsiao,“The impact of rural mutual health care on health status: evaluation of a social experiment in rural China”, Health Economics, vol.18, issue S2, 2009.
Imbens and Wooldridge,“Difference-in-Differences Estimation,Lecture Notes 10, Summer’07”,NBER, 2007.
Jere R. Behrman and Anil B. Deolalikar,“The Intrahousehold Demand for Nutrients in Rural South India: Individual Estimates, Fixed Effects, and Permanent Income”,The Journal of Human Resources, Vol. 25, No. 4 (Autumn, 1990), pp. 665-696.
Leuven, Edwin and Barbara Sianesi,“Psmatch2: Stata Module to perform full Mahalanobis and Propensity Score Matching, Common Support Graphing, and Covariate Imbalance Testing, http://ideas.repec.org/c/boc/bocode/s43200 1.html, version 3.0.0. (Date visited: August 16, 2010) 2003.
Liu Y, Rao K, Hsiao WC.,“Medical Expenditure and Rural Impoverishment in China”, Journal of Health, Population and Nutrition, 21, 2003.
Liu Y.,“Development of the rural health insurance system in China”, Health Policy Plan,19,2004.
Liu Yuanli,“Reforming China’s urban health insurance system”,Health Policy(60):2002.
Lina Song,“In Search of Gender Bias in Household Resource Allocation in Rural China”,IZA Discussion Paper No. 3464. Institute for the Study of Labor (IZA), 2008.
Ling Xu, Yan Wang, Charles D Collins and Shenglan Tang,“Urban health insurance reform and coverage in China using data from National Health Services Surveys in 1998 and 2003”, BMC Health Services Research ,2007.
Mariacristina De Nardi, Eric French, and John Bailey Jones,“Differential Mortality, Uncertain Medical Expenses, and the Saving of Elderly Singles”, NBER Working Paper ,http://bank-banque-canada.ca/en/conference_papers/workshop_may2007/denardi.pdf,2006.
Mengtao Gao and Yang Yao,“Gender Gaps in Access to Health Care in Rural China”,Economic Development and Cultural Change, 55:87–107,2006.
Newhouse,“Medical care costs: how much welfare loss?”, Journal of Economic Perspective, 6, 1992.
Newhouse,“Free for All? Lessons from the RAND Health Insurance Experiment”, Harvard University Press, 1993.
Ramesh Subramaniam,“Gender-Bias in India: The Importance of Household Fixed-Effects”, Oxford Economic Papers, New Series, Vol. 48, No. 2 (Apr., 1996).
Sascha O. Becker,Andrea Ichino,“Estimation of average treatment effects based on propensity scores”, The Stata Journal, 2(4), 2002.
Shin-Yi Chou, Jin-Tan Liu, and James K. Hammitt,“National Health Insurance and precautionary saving:evidence from Taiwan”, Journal of Public Economics 87: 2003.
Smith, Jeffery A., & Petra Todd ,“Does Matching Overcome LaLonde’s Critique of Nonexperimental Estimators?”, Journal of Econometrics, 125, 2005.
陈佳贵主编:《中国社会保障发展报告(1997-2001)》,社会科学文献出版社2001年版。
国务院:《关于建立城镇职工基本医疗保险制度的决定》,http://www.gov.cn/banshi/2005-08/ 04/content_20256.htm,2010年12月17日14点09分。
国务院:《中共中央国务院关于深化医药卫生体制改革的意见》, http://www.gov.cn/jrzg/ 2009-04/06/content_1278721.htm,2010年12月17日14点11分。
郭有德:《医疗费用上涨原因及控制对策研究》,《中国卫生资源》2005年第8卷第3期。
黄枫、甘犁:《过度需求还是有效需求:城镇老人健康与医疗保险的实证分析》,《经济研究》,2010年第6期。
劳动和社会保障部:《关于1992年劳动事业发展的公报》,《中国劳动》1993年第7期。
劳动和社会保障部:《关于1993年劳动事业发展的公报》,http://www.gsjsw.gov.cn/html/ dczltjsj/11_36_18_616.html,2010年3月5日10点18分。
罗楚亮:《城镇居民健康差异与医疗支出行为》,《财经研究》2008年第10期。
罗楚亮、熊晓曦:《新医改可否解决医疗费用上涨之惑》,《西部论丛》2009年第5期。
谢垩:《与收入相关的健康及医疗服务利用不平等研究》,《经济研究》2009年第2期。
俞炳匡:《医疗改革的经济学》,中信出版社2008年版。
宋晓梧、刘浩:“医疗保险制度改革及配套措施”,《中国社会保障体制改革与发展报告》(宋晓梧主笔),中国人民大学出版社2001年版。
宋晓梧:《中国社会保障制度改革》,清华大学出版社2000年版。
宋丽娜:“中国农村家庭资源配置的性别效应”,《中国居民收入分配再研究》,中国财政经济出版社1999年版。
吴要武、赵泉:《高校扩招与大学毕业生就业》,《经济研究》第9期。
卫生部:《1997-2001年我国卫生事业发展情况简报》,http://www.moh.gov.cn/publicfiles/ business/htmlfiles/zwgkzt/pgb/200805/34846.htm,2011年3月3日15点41分。
卫生部:《2008年我国卫生改革与发展情况》,http://www.moh.gov.cn/publicfiles/business/ htmlfiles/mohbgt/s6690/200902/39109.htm,2011年3月3日15点41分。
朱文轶、李菁、王鸿谅、吴琪:《封面故事:垄断的大医院》,《三联生活周刊》总349期,2005年8月22日。
郑秉文、高庆波、于环:“新中国社会保障制度的变迁与发展”,《社会保障绿皮书:中国社会保障发展报告2010,No.4》(陈佳贵、王延中主编),社科文献出版社2010年版。
周亚虹、许玲丽、夏正青,《从农村职业教育看人力资本对农村家庭的贡献》,《经济研究》2010年第8期。