中国成年人医疗保险未参保状况及影响因素研究
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摘要
为了扩大医疗保险覆盖率,中国政府相继实施了城镇职工基本医疗保险、新型农村合作医疗、城镇居民基本医疗保险制度。利用中国家庭追踪调查2010、2012、2014、2016年数据,本研究考察了成年人医疗保险未参保的发生率及未参保的影响因素。描述性统计结果显示,尽管中国近年来医疗保险覆盖率明显增加,但到2016年仍有约7%的成年人没有被医疗保险覆盖。从社会经济地位、逆向选择、制度分割(属地管理)的角度,本研究运用多元统计分析了未参保的影响因素。研究发现:收入、教育水平、过去半年是否患过慢性病、过去一年是否住过院大体上都与未参保显著负相关,表明社会经济地位低和逆向选择问题是构成全民医保实现的障碍;人口(非户籍)流动与未参保显著正相关,表明医保制度的分割性会限制人们参保;在社会保障建设不断推进、政府日益关注弱势群体医疗保障问题的背景下,近年来社会经济水平低和医保制度分割对参保的阻碍作用有所下降。
To expand the coverage of medical insurance nationwide, the Chinese government successively implemented the Urban Employee Basic Medical Insurance Scheme, New Cooperative Rural Medical Scheme, and Urban Resident Basic Medical Insurance Scheme in the past two decades. Using the data from the China Family Panel Studies conducted in 2010, 2012, 2014 and 2016 respectively, we examined the prevalence and social determinants of health non-insurance among Chinese adults. Descriptive results showed that, despite the great increase in the insurance coverage rate, by 2016 about 7 per cent of Chinese adults were still uninsured in any health insurance scheme. Based on the perspectives of ''socioeconomic status' ', ''adverse selection'', and ''institutional segmentation(localized administration)'', we conducted multivariate analyses of social determinants of non-insurance. We found that income, education, inpatient treatment in the last year, and chronic disease in the past half year are all negatively associated with non-insurance, indicating that socioeconomic disadvantages and adverse selection constitute potential barriers for achieving universal insurance coverage. We also found that non-hukou migration is positively associated with noninsurance, indicating that the segmentation of the health insurance system hampers full insurance participation. Along with the government's effort in the development of social security and the endeavor of the medical care access of the socioeconomically disadvantaged, we found some evidence indicating that the infl uences of socioeconomic status and the segmentation of health insurance system on access to insurance have been in decline. Taken as a whole, these findings are enlightening to policymakers who are intent on improving the health insurance system in China.
To expand the coverage of medical insurance nationwide, the Chinese government successively implemented the Urban Employee Basic Medical Insurance Scheme, New Cooperative Rural Medical Scheme, and Urban Resident Basic Medical Insurance Scheme in the past two decades. Using the data from the China Family Panel Studies conducted in 2010, 2012, 2014 and 2016 respectively, we examined the prevalence and social determinants of health non-insurance among Chinese adults. Descriptive results showed that, despite the great increase in the insurance coverage rate, by 2016 about 7 per cent of Chinese adults were still uninsured in any health insurance scheme. Based on the perspectives of ''socioeconomic status' ', ''adverse selection'', and ''institutional segmentation(localized administration)'', we conducted multivariate analyses of social determinants of non-insurance. We found that income, education, inpatient treatment in the last year, and chronic disease in the past half year are all negatively associated with non-insurance, indicating that socioeconomic disadvantages and adverse selection constitute potential barriers for achieving universal insurance coverage. We also found that non-hukou migration is positively associated with noninsurance, indicating that the segmentation of the health insurance system hampers full insurance participation. Along with the government's effort in the development of social security and the endeavor of the medical care access of the socioeconomically disadvantaged, we found some evidence indicating that the infl uences of socioeconomic status and the segmentation of health insurance system on access to insurance have been in decline. Taken as a whole, these findings are enlightening to policymakers who are intent on improving the health insurance system in China.
引文
(1)Qin Gao,et al.,"The Chinese Welfare State in Transition:1988-2007,"Journal of Social Policy,2013,42(4).
(1)顾昕:《走向普遍覆盖:全民医疗保险面临的挑战》,《东岳论丛》2010年第1期;赵绍阳等:《强制医保制度下无保险人群的健康状况研究》,《经济研究》2013年第7期。
(2)参见国务院:《“十三五”深化医药卫生体制改革规划》,中国政府网:http://www.gov.cn/zhengce/content/2017-01/09/content_5158053.htm,2016年12月27日。
(3)Gail Henderson,et al.,"Distribution of Medical Insurance in China,"Social Science&Medicine,1995,41(8);Teh-wei Hu,et al.,"The Eff ects of Economic Reform on Health Insurance and the Financial Burden for Urban Workers in China,"Health Economics 1999,8(4);Weixiang Luo,Yuying Tong,"Educational Disparities in Access to Health Insurance in China,1989-2009,"Chinese Sociological Review,2016,48(2).
(4)Wanchuan Lin,et al.,"The Urban Resident Basic Medical Insurance:A Landmark Reform towards Universal Coverage in China,"Health Economics,2009,18(S);藏文斌等:《城镇基本医疗保险中逆向选择的检验》,《经济学(季刊)》2012年第1期;朱信凯、彭廷军:《新型农村合作医疗中的“逆向选择”问题:理论研究与实证分析》,《管理世界》2009年第1期。
(5)Jennifer Karas Montez,et al.,"Employment,Marriage,and Inequality in Health Insurance for Mexican-origin Women,"Journal of Health and Social Behavior,2009,50(2).
(1)Indu B.Ahluwalia,Julie Bolen,"Lack of Health Insurance Coverage among Working-age Adults,Evidence from the Behavioral Risk Factor Surveillance System,1993-2006,"Journal of Community Health,2008,33(5);Karen Seccombe,Cheryl Amey,"Playing by the Rules and Losing:Health Insurance and the Working Poor,"Journal of Health and Social Behavior,1995,36(2).
(2)参见Phyllis Moen,Patricia Roehling,The Career Mystique:Cracks in the American Dream,Rowman&Littlefi eld Publishers,Inc.,2005.
(3)Paul Fronstin,Employment-Based Health Benefi ts:Access and Coverage,1988-2005,Issue Briefs,Employee Benefi t Research Institute,Washington,D.C.,2007,No.303;Karen Seccombe,"Employer Sponsored Medical Benefi ts:The Influence of Occupational Characteristics and Gender,"The Sociological Quarterly,1993,34(4);Karen Seccombe,Leonard Beeghley,"Gender and Medical Insurance:A Test of Human Capital Theory,"Gender&Society,1992,6(2).
(4)藏文斌等:《城镇基本医疗保险中逆向选择的检验》,《经济学(季刊)》2012年第1期。
(1)参见G?sta Esping-Andersen,The Three Worlds of Welfare Capitalism,Princeton University Press,1990.
(2)Qin Gao,et al.,"The Chinese Welfare State in Transition:1988-2007,"Journal of Social Policy,2013,42(4).
(3)参见G?sta Esping-Andersen,The Three Worlds of Welfare Capitalism,Princeton University Press,1990.
(4)David Blumenthal,William Hsiao,"Privatization and its Discontents-The Evolving Chinese Health Care System,"New England Journal of Medicine,2005,353(11).
(5)赵绍阳等:《强制医保制度下无保险人群的健康状况研究》,《经济研究》2013年第7期。
(6)Teh-wei Hu,et al.,"The Eff ects of Economic Reform on Health Insurance and the Financial Burden for Urban Workers in China,"Health Economics 1999,8(4).
(7)张欢:《中国社会保险逆向选择问题的理论分析与实证研究》,《管理世界》2006年第2期。
(1)藏文斌等:《城镇基本医疗保险中逆向选择的检验》,《经济学(季刊)》2012年第1期。
(2)朱信凯、彭廷军:《新型农村合作医疗中的“逆向选择”问题:理论研究与实证分析》,《管理世界》2009年第1期。
(3) Thomas M.Selden,"Premium Subsidies for Health Insurance:Excessive Coverage vs.Adverse Selection,"Journal of Health Economics,1999,18(6).
(1)Wanchuan Lin,et al.,"The Urban Resident Basic Medical Insurance:A Landmark Reform towards Universal Coverage in China,"Health Economics,2009,18(S);藏文斌等:《城镇基本医疗保险中逆向选择的检验》,《经济学(季刊)》2012年第1期。
(1)参见Sophia Rabe-Hesketh,Anders Skrondal,Multilevel and Longitudinal Modeling Using Stata,STATA Press,2008.
(2)个体层次固定效应模型结果与随机截距模型的结果基本一致。若需要,可向作者索取。
(1) Indu B.Ahluwalia,Julie Bolen,"Lack of Health Insurance Coverage among Working-age Adults,Evidence from the Behavioral Risk Factor Surveillance System,1993-2006,"Journal of Community Health,2008,33(5);Paul Fronstin,Employment-Based Health Benefi ts:Access and Coverage,1988-2005,Issue Briefs,Employee Benefi t Research Institute,Washington,D.C.,2007,No.303;David E.Nelson,et al.,"State Trends in Uninsurance among Individuals Aged 18-64Years:United States,1992-2001,"American Journal of Public Health,2004,94(11);Karen Seccombe,"Employer Sponsored Medical Benefi ts:The Infl uence of Occupational Characteristics and Gender,"The Sociological Quarterly,1993,34(4);Karen Seccombe,Cheryl Amey,"Playing by the Rules and Losing:Health Insurance and the Working Poor,"Journal of Health and Social Behavior,1995,36(2).
(2)Yaohui Zhao,"Labor Migration and Earnings Diff erences:The Case of China,"Economic Development and Cultural Change,1999,47(4).
(1)齐亚强等:《我国人口流动中的健康选择机制研究》,《人口研究》2012年第1期;Yuying Tong,Martin Piotrowski,"Migration and Health Selectivity in the Context of Internal Migration in China,1997-2009,"Population Research and Policy Review,2012,31(4).
(1)参见国务院:《“十三五”深化医药卫生体制改革规划》,中国政府网:http://www.gov.cn/zhengce/content/2017-01/09/content_5158053.htm,2016年12月27日。
(2) Weixiang Luo,Yuying Tong,"Educational Disparities in Access to Health Insurance in China,1989-2009,"Chinese Sociological Review,2016,48(2).
(3)白重恩等:《医疗保险与消费:来自新型农村合作医疗的证据》,《经济研究》2012年第2期;潘杰等:《医疗保险促进健康吗?--基于中国城镇居民基本医疗保险的实证分析》,《经济研究》2013年第4期;於嘉:《我国医疗保险制度福利效应评估》,《财经问题研究》2015年第12期;臧文斌等:《中国城镇居民基本医疗保险对家庭消费的影响》,《经济研究》2012年第7期;赵绍阳等:《强制医保制度下无保险人群的健康状况研究》,《经济研究》2013年第7期。
(4)朱信凯、彭廷军:《新型农村合作医疗中的“逆向选择”问题:理论研究与实证分析》,《管理世界》2009年第1期。
(1)朱信凯、彭廷军:《新型农村合作医疗中的“逆向选择”问题:理论研究与实证分析》,《管理世界》2009年第1期。
(2)齐亚强等:《我国人口流动中的健康选择机制研究》,《人口研究》2012年第1期;Yuying Tong,Martin Piotrowski,"Migration and Health Selectivity in the Context of Internal Migration in China,1997-2009,"Population Research and Policy Review,2012,31(4).
(3)藏文斌等:《城镇基本医疗保险中逆向选择的检验》,《经济学(季刊)》2012年第1期;朱信凯、彭廷军:《新型农村合作医疗中的“逆向选择”问题:理论研究与实证分析》,《管理世界》2009年第1期。
(1)顾昕:《走向普遍覆盖:全民医疗保险面临的挑战》,《东岳论丛》2010年第1期;赵绍阳等:《强制医保制度下无保险人群的健康状况研究》,《经济研究》2013年第7期。
(2)参见国务院:《“十三五”深化医药卫生体制改革规划》,中国政府网:http://www.gov.cn/zhengce/content/2017-01/09/content_5158053.htm,2016年12月27日。
(3)Gail Henderson,et al.,"Distribution of Medical Insurance in China,"Social Science&Medicine,1995,41(8);Teh-wei Hu,et al.,"The Eff ects of Economic Reform on Health Insurance and the Financial Burden for Urban Workers in China,"Health Economics 1999,8(4);Weixiang Luo,Yuying Tong,"Educational Disparities in Access to Health Insurance in China,1989-2009,"Chinese Sociological Review,2016,48(2).
(4)Wanchuan Lin,et al.,"The Urban Resident Basic Medical Insurance:A Landmark Reform towards Universal Coverage in China,"Health Economics,2009,18(S);藏文斌等:《城镇基本医疗保险中逆向选择的检验》,《经济学(季刊)》2012年第1期;朱信凯、彭廷军:《新型农村合作医疗中的“逆向选择”问题:理论研究与实证分析》,《管理世界》2009年第1期。
(5)Jennifer Karas Montez,et al.,"Employment,Marriage,and Inequality in Health Insurance for Mexican-origin Women,"Journal of Health and Social Behavior,2009,50(2).
(1)Indu B.Ahluwalia,Julie Bolen,"Lack of Health Insurance Coverage among Working-age Adults,Evidence from the Behavioral Risk Factor Surveillance System,1993-2006,"Journal of Community Health,2008,33(5);Karen Seccombe,Cheryl Amey,"Playing by the Rules and Losing:Health Insurance and the Working Poor,"Journal of Health and Social Behavior,1995,36(2).
(2)参见Phyllis Moen,Patricia Roehling,The Career Mystique:Cracks in the American Dream,Rowman&Littlefi eld Publishers,Inc.,2005.
(3)Paul Fronstin,Employment-Based Health Benefi ts:Access and Coverage,1988-2005,Issue Briefs,Employee Benefi t Research Institute,Washington,D.C.,2007,No.303;Karen Seccombe,"Employer Sponsored Medical Benefi ts:The Influence of Occupational Characteristics and Gender,"The Sociological Quarterly,1993,34(4);Karen Seccombe,Leonard Beeghley,"Gender and Medical Insurance:A Test of Human Capital Theory,"Gender&Society,1992,6(2).
(4)藏文斌等:《城镇基本医疗保险中逆向选择的检验》,《经济学(季刊)》2012年第1期。
(1)参见G?sta Esping-Andersen,The Three Worlds of Welfare Capitalism,Princeton University Press,1990.
(2)Qin Gao,et al.,"The Chinese Welfare State in Transition:1988-2007,"Journal of Social Policy,2013,42(4).
(3)参见G?sta Esping-Andersen,The Three Worlds of Welfare Capitalism,Princeton University Press,1990.
(4)David Blumenthal,William Hsiao,"Privatization and its Discontents-The Evolving Chinese Health Care System,"New England Journal of Medicine,2005,353(11).
(5)赵绍阳等:《强制医保制度下无保险人群的健康状况研究》,《经济研究》2013年第7期。
(6)Teh-wei Hu,et al.,"The Eff ects of Economic Reform on Health Insurance and the Financial Burden for Urban Workers in China,"Health Economics 1999,8(4).
(7)张欢:《中国社会保险逆向选择问题的理论分析与实证研究》,《管理世界》2006年第2期。
(1)藏文斌等:《城镇基本医疗保险中逆向选择的检验》,《经济学(季刊)》2012年第1期。
(2)朱信凯、彭廷军:《新型农村合作医疗中的“逆向选择”问题:理论研究与实证分析》,《管理世界》2009年第1期。
(3) Thomas M.Selden,"Premium Subsidies for Health Insurance:Excessive Coverage vs.Adverse Selection,"Journal of Health Economics,1999,18(6).
(1)Wanchuan Lin,et al.,"The Urban Resident Basic Medical Insurance:A Landmark Reform towards Universal Coverage in China,"Health Economics,2009,18(S);藏文斌等:《城镇基本医疗保险中逆向选择的检验》,《经济学(季刊)》2012年第1期。
(1)参见Sophia Rabe-Hesketh,Anders Skrondal,Multilevel and Longitudinal Modeling Using Stata,STATA Press,2008.
(2)个体层次固定效应模型结果与随机截距模型的结果基本一致。若需要,可向作者索取。
(1) Indu B.Ahluwalia,Julie Bolen,"Lack of Health Insurance Coverage among Working-age Adults,Evidence from the Behavioral Risk Factor Surveillance System,1993-2006,"Journal of Community Health,2008,33(5);Paul Fronstin,Employment-Based Health Benefi ts:Access and Coverage,1988-2005,Issue Briefs,Employee Benefi t Research Institute,Washington,D.C.,2007,No.303;David E.Nelson,et al.,"State Trends in Uninsurance among Individuals Aged 18-64Years:United States,1992-2001,"American Journal of Public Health,2004,94(11);Karen Seccombe,"Employer Sponsored Medical Benefi ts:The Infl uence of Occupational Characteristics and Gender,"The Sociological Quarterly,1993,34(4);Karen Seccombe,Cheryl Amey,"Playing by the Rules and Losing:Health Insurance and the Working Poor,"Journal of Health and Social Behavior,1995,36(2).
(2)Yaohui Zhao,"Labor Migration and Earnings Diff erences:The Case of China,"Economic Development and Cultural Change,1999,47(4).
(1)齐亚强等:《我国人口流动中的健康选择机制研究》,《人口研究》2012年第1期;Yuying Tong,Martin Piotrowski,"Migration and Health Selectivity in the Context of Internal Migration in China,1997-2009,"Population Research and Policy Review,2012,31(4).
(1)参见国务院:《“十三五”深化医药卫生体制改革规划》,中国政府网:http://www.gov.cn/zhengce/content/2017-01/09/content_5158053.htm,2016年12月27日。
(2) Weixiang Luo,Yuying Tong,"Educational Disparities in Access to Health Insurance in China,1989-2009,"Chinese Sociological Review,2016,48(2).
(3)白重恩等:《医疗保险与消费:来自新型农村合作医疗的证据》,《经济研究》2012年第2期;潘杰等:《医疗保险促进健康吗?--基于中国城镇居民基本医疗保险的实证分析》,《经济研究》2013年第4期;於嘉:《我国医疗保险制度福利效应评估》,《财经问题研究》2015年第12期;臧文斌等:《中国城镇居民基本医疗保险对家庭消费的影响》,《经济研究》2012年第7期;赵绍阳等:《强制医保制度下无保险人群的健康状况研究》,《经济研究》2013年第7期。
(4)朱信凯、彭廷军:《新型农村合作医疗中的“逆向选择”问题:理论研究与实证分析》,《管理世界》2009年第1期。
(1)朱信凯、彭廷军:《新型农村合作医疗中的“逆向选择”问题:理论研究与实证分析》,《管理世界》2009年第1期。
(2)齐亚强等:《我国人口流动中的健康选择机制研究》,《人口研究》2012年第1期;Yuying Tong,Martin Piotrowski,"Migration and Health Selectivity in the Context of Internal Migration in China,1997-2009,"Population Research and Policy Review,2012,31(4).
(3)藏文斌等:《城镇基本医疗保险中逆向选择的检验》,《经济学(季刊)》2012年第1期;朱信凯、彭廷军:《新型农村合作医疗中的“逆向选择”问题:理论研究与实证分析》,《管理世界》2009年第1期。