财政卫生支出:提升健康与降低费用——兼论企业医保降费
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摘要
2009年我国新一轮医药卫生体制改革(以下简称"新医改")启动以来,财政卫生支出呈现出新的特点:一是财政对供方的投入重点由公立医院转向基层医疗卫生服务("强基层");二是财政补贴重点从医疗卫生机构转向医疗保障("补需方")。那么,新医改以来财政支出对提升健康水平、降低医疗费用的作用如何?本文利用2009—2016年我国省级面板数据,使用系统GMM估计方法对此进行了实证分析,结果发现:(1)财政卫生支出显著促进了居民的医疗服务利用,"强基层"和"补需方"均显著改善了居民健康。这表明财政卫生支出是必要的,还可以降低当前较高的企业医保缴费负担。(2)财政卫生支出对医疗费用、个人医疗负担的影响尚不确定,"强基层"降低了医疗费用,减轻了医疗负担,"补需方"则相反。本文的主要建议是政府应当坚持对基层医疗卫生服务的投入,同时加强医保的科学控费机制建设,并特别为降低企业医保缴费腾出空间。
A new healthcare reform plan was released to the public in 2009.A central feature of this reform was a call for the government health expenditure.Since New Healthcare Reform,China's government health expenditure has shown some new features.On the one hand,the focus of financial input to suppliers of medical service has shifted from public hospitals to primary health institutions(Subsidy primary service),on the other hand,government changed its focus from subsidizing medical institutions to subsidizing medical security(Subsidy demand side).Subsidizing primary care service and basic medical security have become the largest part of government health expenditure.Whether the government health expenditure policy should be insisted depends on the effect of these inputs on improving health.Based on 2009-2016 provincial panel data and system GMM estimate method,this paper constructs two key variables to measure government health expenditure directly and examines the effect of government health expenditure on health and medical expense with estimate method.In the model of outpatient medical service utilization,the coefficient of subsiding primary service is significantly positive but not significant on inpatient service,indicating that the financial input on primary healthcare service can improve the accessibility of medical service to a certain extent since New Healthcare Reform,especially on outpatient service.The coefficient of subsiding demand side on inpatient medical service utilization is significantly positive,but not significant on outpatient service utilization.This indicates that financial input on basic medical insurance has improved accessibility of medical services,which also be consistent with medical insurance policy that mainly compensates hospitalization expenses.In the model of health,the coefficient of subsiding primary service on maternal mortality and perinatal mortality are significantly negative,indicating that financial input on primary medical service can improve people's health status.This may be related to the improvement of accessibility of medical service,which help avoid disease deterioration caused by delays in treatment.The coefficient of subsiding demand side on maternal mortality is significantly negative,and the coefficient on perinatal mortality is negative but not significant.This shows that financial input on medical insurance can improve people's health level.Consistent with the finding above,subsiding demand side promotes the use of medical services,then improve health.Moreover,China's current medical insurance is still in a stage of wide coverage and low level of protection,medical expenditure has a high marginal output for health,thus increasing input on medical security has positive effect on improving health.In the model of medical expenditure,the coefficient of subsiding primary service on medical expenditure is negative but not significant,and the coefficient on personal medical burden is significantly negative.This shows that financial input on primary services can reduce the growth of medical expenses to a certain extent and effectively reduce the personal medical burden.However,the coefficients of subsiding demand side on medical expenses and medical burden are significantly positive,indicating that medical insurance has contributed to the increase of medical expenses.In general,the results show that financial input on either primary service or basic medical insurance has positive effect on improving health and decreasing medical expenditures to a certain extent.In detail,government health expenditure stimulates both inpatient and outpatient medical service utilization,hence improves the health status,whether subsiding primary service or demand side.But it's unsure that how the government health expenditure affects the medical expense.Subsiding primary services can reduce both medical expense and medical burden while subsiding demand side can't.Therefore,the paper suggests that for better health status and controllable medical expenditure government should keep increasing the input to public health and basic medical services and strengthening the construction of cost control mechanism of medical insurance.
A new healthcare reform plan was released to the public in 2009.A central feature of this reform was a call for the government health expenditure.Since New Healthcare Reform,China's government health expenditure has shown some new features.On the one hand,the focus of financial input to suppliers of medical service has shifted from public hospitals to primary health institutions(Subsidy primary service),on the other hand,government changed its focus from subsidizing medical institutions to subsidizing medical security(Subsidy demand side).Subsidizing primary care service and basic medical security have become the largest part of government health expenditure.Whether the government health expenditure policy should be insisted depends on the effect of these inputs on improving health.Based on 2009-2016 provincial panel data and system GMM estimate method,this paper constructs two key variables to measure government health expenditure directly and examines the effect of government health expenditure on health and medical expense with estimate method.In the model of outpatient medical service utilization,the coefficient of subsiding primary service is significantly positive but not significant on inpatient service,indicating that the financial input on primary healthcare service can improve the accessibility of medical service to a certain extent since New Healthcare Reform,especially on outpatient service.The coefficient of subsiding demand side on inpatient medical service utilization is significantly positive,but not significant on outpatient service utilization.This indicates that financial input on basic medical insurance has improved accessibility of medical services,which also be consistent with medical insurance policy that mainly compensates hospitalization expenses.In the model of health,the coefficient of subsiding primary service on maternal mortality and perinatal mortality are significantly negative,indicating that financial input on primary medical service can improve people's health status.This may be related to the improvement of accessibility of medical service,which help avoid disease deterioration caused by delays in treatment.The coefficient of subsiding demand side on maternal mortality is significantly negative,and the coefficient on perinatal mortality is negative but not significant.This shows that financial input on medical insurance can improve people's health level.Consistent with the finding above,subsiding demand side promotes the use of medical services,then improve health.Moreover,China's current medical insurance is still in a stage of wide coverage and low level of protection,medical expenditure has a high marginal output for health,thus increasing input on medical security has positive effect on improving health.In the model of medical expenditure,the coefficient of subsiding primary service on medical expenditure is negative but not significant,and the coefficient on personal medical burden is significantly negative.This shows that financial input on primary services can reduce the growth of medical expenses to a certain extent and effectively reduce the personal medical burden.However,the coefficients of subsiding demand side on medical expenses and medical burden are significantly positive,indicating that medical insurance has contributed to the increase of medical expenses.In general,the results show that financial input on either primary service or basic medical insurance has positive effect on improving health and decreasing medical expenditures to a certain extent.In detail,government health expenditure stimulates both inpatient and outpatient medical service utilization,hence improves the health status,whether subsiding primary service or demand side.But it's unsure that how the government health expenditure affects the medical expense.Subsiding primary services can reduce both medical expense and medical burden while subsiding demand side can't.Therefore,the paper suggests that for better health status and controllable medical expenditure government should keep increasing the input to public health and basic medical services and strengthening the construction of cost control mechanism of medical insurance.
引文
[1]傅子恒,刘小兵.我国医疗资源配置中的政府管制及其改进空间[J].北京:经济管理,2010,(9):156-161.
[2]顾昕.公共财政转型与政府卫生筹资责任的回归[J].北京:中国社会科学,2010,(2):103-120.
[3]毛捷,赵金冉.政府公共卫生投入的经济效应——基于农村居民消费的检验[J].北京:中国社会科学,2017,(10):70-89.
[4]李华,俞卫.政府卫生支出对中国农村居民健康的影响[J].北京:中国社会科学,2013,(10):41-60.
[5]赵大海,陆露露.政府与市场:英美两国基层医疗卫生系统改革进程对我国的启示[J].杭州:浙江大学学报(人文社会科学版),2017,(47):176-184.
[6]Koperski M.The State of Primary Care in the United States of America and Lessons for Primary Care Groups in the United Kingdom[J].Br J Gen Pract,2000,(50):319-322.
[7]Starfield B.,and L.Shi.Policy Relevant Determinants of Health:An International Perspective[J].Health Policy,2002,(60):201-218.
[8]Starfield B.,L.Shi,and J.Macinko.Contribution of Primary Care to Health Systems and Health[J].The Milbank Quarterly,2005,(83):457-502.
[9]Franks P.,and K.Fiscella.Primary Care Physicians and Specialists as Personal Physicians:Health Care Expenditures and Mortality Experience[J].Journal of Family Practice,1998,(47):105-110.
[10]Baicker K.,and A.Chandra.Medicare Spending,the Physician Workforce,and Beneficiaries' Quality of Care[R].UCLA CCPR Population Working Papers,2005.
[11]方鹏骞,董四平,肖婧婧.中国政府卫生投入的制度变迁与路径选择[J].武汉大学学报(哲学社会科学版),2009,(62):201-212.
[12]张宏翔,张明宗,熊波.财政分权、政府竞争和地方公共卫生投入[J].北京:财政研究,2014,(8):33-37.
[13]范世祥,梁宝敏,龙莉莉,刘国艳.广西基层医疗卫生机构财政补助政策研究[J].北京:经济研究参考,2011,(17):19-23.
[14]刘明慧.公共财政医疗卫生投入问题分析[J].大连海事大学学报(社会科学版),2005,(2):62-66.
[15]倪世树.按服务数量补助基层医疗卫生机构的实践探索[J].杭州:卫生经济研究,2014,(4):49-52.
[16]应亚珍,戈昕,徐明明,李杰,徐鸿,刘永华,高广颖.基层医疗卫生机构“收支两条线”的比较研究[J].杭州:卫生经济研究,2016,(9):8-12.
[17]张文斌,杨铭星,牟晋超,陈雄,李雪君.基层医疗卫生机构财政补偿机制改革的实证研究——以浙江省义乌市为例[J].杭州:卫生经济研究,2017,(11):42-44.
[18]李海林,邹志辉.广州市基本公共卫生服务实施现状及对策探讨[J].哈尔滨:中国初级卫生保健,2016,(30):8-9.
[19]Jaspersen J.,and A.Richter.The Influence of Premium Subsidies on Moral Hazard in Insurance Contracts[R].Munich Risk and Insurance Center (MRIC) Working Paper,2013.
[20]封进,刘芳,陈沁.新型农村合作医疗对县村两级医疗价格的影响[J].北京:经济研究,2010,(45):127-140.
[21]申曙光.新时期我国社会医疗保险体系的改革与发展[J].北京:社会保障评论,2017,(1):40-53.
[22]Lei X.,and W.Lin.The New Cooperative Medical Scheme in Rural China:Does More Coverage Mean More Service and Better Health?[J].Health Economics,2009,(18):S25-S46.
[23]刘国恩,蔡春光,李林.中国老人医疗保障与医疗服务需求的实证分析[J].北京:经济研究,2011,(46):95-107.
[24]程令国,张晔.“新农合”:经济绩效还是健康绩效?[J].北京:经济研究,2012,(47):120-133.
[25]Chen Y.,and G.Z.Jin.Does Health Insurance Coverage Lead to Better Health and Educational Outcomes? Evidence from Rural China[J].Journal of Health Economics,2012,(31):1-14.
[26]胡宏伟,刘国恩.城镇居民医疗保险对国民健康的影响效应与机制[J].广州:南方经济,2012,(10):186-199.
[27]潘杰,雷晓燕,刘国恩.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[J].北京:经济研究,2013,(48):130-142.
[28]Finkelstein A.,S.Taubman,B.Wright,et al..The Oregon Health Insurance Experiment:Evidence from the First Year[J].The Quarterly Journal of Economics,2012,(127):1057-1106.
[29]王新军,郑超.医疗保险对老年人医疗支出与健康的影响[J].上海:财经研究,2014,(40):65-75.
[30]Wagstaff A.,M.Lindelow,and G.Jun,et al..Extending Health Insurance to the Rural Population:An Impact Evaluation of China’s New Cooperative Medical Scheme[J].Journal of Health Economics,2009,(28):1-19.
[31]Yip W.,and W.C.Hsiao.Non-Evidence-Based Policy:How Effective Is China's New Cooperative Medical Scheme in Reducing Medical Impoverishment?[J].Social Science & Medicine,2009,(68):201-209.
[32]王俊.中国政府卫生支出规模研究——三个误区及经验证据[J].北京:管理世界,2007,(2):27-36.
[33]郝曙霞.简议医改中乡镇卫生院发展的瓶颈[J].北京:中国农村卫生,2013,(11):25-26.
[34]Finkelstein A.,E.F.Luttmer,and M.J.Notowidigdo.Approaches to Estimating the Health State Dependence of the Utility Function[J].American Economic Review,2009,(99):116-121.
[35]李湘君,王中华,林振平.新型农村合作医疗对农民就医行为及健康的影响——基于不同收入层次的分析[J].上海:世界经济文汇,2012,(3):58-75.
[36]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[J].北京:经济研究,2010,(45):105-119.
[37]谢明明,王美娇,熊先军.道德风险还是医疗需求释放?——医疗保险与医疗费用增长[J].北京:保险研究,2016,(1):102-112.
①根据《中国卫生和计划生育统计年鉴》计算得到。
②国外对公共卫生支出的统计口径与中国有所差异,国外将社会医疗保险收入也视为公共财政投入。本文采用国内的统计口径,也有文献采用政府卫生支出这一说法。
(1)《关于完善政府卫生投入政策的意见》(财社[2009]66号)。
(2)根据《中国统计年鉴》数据计算得到。
(3)人均医疗保健支出是以城镇居民人均医疗保健支出、农村居民人均医疗保健支出进行加权平均得到,权重为城镇人口、农村人口所占比重。人均可支配收入的计算方法同上。
(4)由于各省经济发展水平财政实力不同,中西部地区的财政补贴由中央和地方进行分担,经济较发达的东部地区则主要由地方承担。财政对参保人的补贴标准,由中央政府规定最低标准,各省可在此基础上增加。通过对各省补贴标准的分析发现,绝大部分省份的补贴标准与中央政府规定的标准相近。因此,本文采用中央政府要求的补贴标准进行计算。
(5)数据来源为《中国统计年鉴》。
[2]顾昕.公共财政转型与政府卫生筹资责任的回归[J].北京:中国社会科学,2010,(2):103-120.
[3]毛捷,赵金冉.政府公共卫生投入的经济效应——基于农村居民消费的检验[J].北京:中国社会科学,2017,(10):70-89.
[4]李华,俞卫.政府卫生支出对中国农村居民健康的影响[J].北京:中国社会科学,2013,(10):41-60.
[5]赵大海,陆露露.政府与市场:英美两国基层医疗卫生系统改革进程对我国的启示[J].杭州:浙江大学学报(人文社会科学版),2017,(47):176-184.
[6]Koperski M.The State of Primary Care in the United States of America and Lessons for Primary Care Groups in the United Kingdom[J].Br J Gen Pract,2000,(50):319-322.
[7]Starfield B.,and L.Shi.Policy Relevant Determinants of Health:An International Perspective[J].Health Policy,2002,(60):201-218.
[8]Starfield B.,L.Shi,and J.Macinko.Contribution of Primary Care to Health Systems and Health[J].The Milbank Quarterly,2005,(83):457-502.
[9]Franks P.,and K.Fiscella.Primary Care Physicians and Specialists as Personal Physicians:Health Care Expenditures and Mortality Experience[J].Journal of Family Practice,1998,(47):105-110.
[10]Baicker K.,and A.Chandra.Medicare Spending,the Physician Workforce,and Beneficiaries' Quality of Care[R].UCLA CCPR Population Working Papers,2005.
[11]方鹏骞,董四平,肖婧婧.中国政府卫生投入的制度变迁与路径选择[J].武汉大学学报(哲学社会科学版),2009,(62):201-212.
[12]张宏翔,张明宗,熊波.财政分权、政府竞争和地方公共卫生投入[J].北京:财政研究,2014,(8):33-37.
[13]范世祥,梁宝敏,龙莉莉,刘国艳.广西基层医疗卫生机构财政补助政策研究[J].北京:经济研究参考,2011,(17):19-23.
[14]刘明慧.公共财政医疗卫生投入问题分析[J].大连海事大学学报(社会科学版),2005,(2):62-66.
[15]倪世树.按服务数量补助基层医疗卫生机构的实践探索[J].杭州:卫生经济研究,2014,(4):49-52.
[16]应亚珍,戈昕,徐明明,李杰,徐鸿,刘永华,高广颖.基层医疗卫生机构“收支两条线”的比较研究[J].杭州:卫生经济研究,2016,(9):8-12.
[17]张文斌,杨铭星,牟晋超,陈雄,李雪君.基层医疗卫生机构财政补偿机制改革的实证研究——以浙江省义乌市为例[J].杭州:卫生经济研究,2017,(11):42-44.
[18]李海林,邹志辉.广州市基本公共卫生服务实施现状及对策探讨[J].哈尔滨:中国初级卫生保健,2016,(30):8-9.
[19]Jaspersen J.,and A.Richter.The Influence of Premium Subsidies on Moral Hazard in Insurance Contracts[R].Munich Risk and Insurance Center (MRIC) Working Paper,2013.
[20]封进,刘芳,陈沁.新型农村合作医疗对县村两级医疗价格的影响[J].北京:经济研究,2010,(45):127-140.
[21]申曙光.新时期我国社会医疗保险体系的改革与发展[J].北京:社会保障评论,2017,(1):40-53.
[22]Lei X.,and W.Lin.The New Cooperative Medical Scheme in Rural China:Does More Coverage Mean More Service and Better Health?[J].Health Economics,2009,(18):S25-S46.
[23]刘国恩,蔡春光,李林.中国老人医疗保障与医疗服务需求的实证分析[J].北京:经济研究,2011,(46):95-107.
[24]程令国,张晔.“新农合”:经济绩效还是健康绩效?[J].北京:经济研究,2012,(47):120-133.
[25]Chen Y.,and G.Z.Jin.Does Health Insurance Coverage Lead to Better Health and Educational Outcomes? Evidence from Rural China[J].Journal of Health Economics,2012,(31):1-14.
[26]胡宏伟,刘国恩.城镇居民医疗保险对国民健康的影响效应与机制[J].广州:南方经济,2012,(10):186-199.
[27]潘杰,雷晓燕,刘国恩.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[J].北京:经济研究,2013,(48):130-142.
[28]Finkelstein A.,S.Taubman,B.Wright,et al..The Oregon Health Insurance Experiment:Evidence from the First Year[J].The Quarterly Journal of Economics,2012,(127):1057-1106.
[29]王新军,郑超.医疗保险对老年人医疗支出与健康的影响[J].上海:财经研究,2014,(40):65-75.
[30]Wagstaff A.,M.Lindelow,and G.Jun,et al..Extending Health Insurance to the Rural Population:An Impact Evaluation of China’s New Cooperative Medical Scheme[J].Journal of Health Economics,2009,(28):1-19.
[31]Yip W.,and W.C.Hsiao.Non-Evidence-Based Policy:How Effective Is China's New Cooperative Medical Scheme in Reducing Medical Impoverishment?[J].Social Science & Medicine,2009,(68):201-209.
[32]王俊.中国政府卫生支出规模研究——三个误区及经验证据[J].北京:管理世界,2007,(2):27-36.
[33]郝曙霞.简议医改中乡镇卫生院发展的瓶颈[J].北京:中国农村卫生,2013,(11):25-26.
[34]Finkelstein A.,E.F.Luttmer,and M.J.Notowidigdo.Approaches to Estimating the Health State Dependence of the Utility Function[J].American Economic Review,2009,(99):116-121.
[35]李湘君,王中华,林振平.新型农村合作医疗对农民就医行为及健康的影响——基于不同收入层次的分析[J].上海:世界经济文汇,2012,(3):58-75.
[36]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[J].北京:经济研究,2010,(45):105-119.
[37]谢明明,王美娇,熊先军.道德风险还是医疗需求释放?——医疗保险与医疗费用增长[J].北京:保险研究,2016,(1):102-112.
①根据《中国卫生和计划生育统计年鉴》计算得到。
②国外对公共卫生支出的统计口径与中国有所差异,国外将社会医疗保险收入也视为公共财政投入。本文采用国内的统计口径,也有文献采用政府卫生支出这一说法。
(1)《关于完善政府卫生投入政策的意见》(财社[2009]66号)。
(2)根据《中国统计年鉴》数据计算得到。
(3)人均医疗保健支出是以城镇居民人均医疗保健支出、农村居民人均医疗保健支出进行加权平均得到,权重为城镇人口、农村人口所占比重。人均可支配收入的计算方法同上。
(4)由于各省经济发展水平财政实力不同,中西部地区的财政补贴由中央和地方进行分担,经济较发达的东部地区则主要由地方承担。财政对参保人的补贴标准,由中央政府规定最低标准,各省可在此基础上增加。通过对各省补贴标准的分析发现,绝大部分省份的补贴标准与中央政府规定的标准相近。因此,本文采用中央政府要求的补贴标准进行计算。
(5)数据来源为《中国统计年鉴》。