健康冲击对农户贫困影响的分析
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摘要
农户作为我国最基本的社会经济单元,在生产和消费过程中不得不直面各种风险,在所有的风险集中,疾病风险的危害更为严重和深远。当疾病产生的大额医疗费用超过家庭的支付能力时,就会造成收入视角的贫困,即所说的“因病致贫”、“因病返贫”。但从可行能力的视角来看,疾病造成的贫困不仅仅是收入贫困,更重要的是可行能力的剥夺,会降低获取收入的能力,并使得将收入转化为可行能力更加困难。因此,疾病产生的“真实贫困”可能比在收入空间表现出来的贫困更加严重,可能具有持久性,甚至发生代际传递。
面对大病冲击带来的福利的损失,农户并不只是消极地承受,而是努力通过多种途径来积极应对。农户的风险应对机制包括正式的和非正式的。在正式的健康保障制度不完善的情况下,农户依靠非正式的应对机制来化解疾病的经济风险,这也是农户的“理性选择”。
风险因素、风险暴露、风险反应或处理策略以及福利后果构成一条完整的风险链。风险链的起点是各种各样的风险,风险的存在并不会直接产生负向影响,只有当风险暴露后才会影响家庭的福利水平。风险的处理策略包括事前行为以及事后的处理策略。在本研究中,我们选取健康风险作为研究重点,并以家庭实际受到健康冲击作为研究的起点,而且主要考虑事后的风险应对策略。将健康风险暴露(健康冲击)、福利后果(贫困)以及健康风险应对策略纳入统一的分析框架。全文主要沿两条主线展开：一是从健康风险的角度审视我国农村的贫困现象,分析健康冲击对家庭贫困的影响,包括贫困的动态变化,即因病致贫的作用过程；二是选取新型农村合作医疗制度、社会网络内的风险统筹分别作为正式的和非正式的风险应对策略的研究重点,探究两种不同的应对策略能否起到缓解我国农村因病致贫的效果。具体研究内容陈述如下：
研究内容一：因病致贫的宏观现状及成因分析
该部分的目的是为后面章节的实证分析奠定研究背景。目前,疾病已成为农户致贫的重要原因之一。由于农村居民收入偏低,医疗服务的经济可及性差,出现患病不就诊,应住院而未住院的现象。而政府卫生事业投入的不足以及城乡之间医疗资源配置的不平衡,也导致农民获得医疗服务的能力远远弱于城镇居民。医疗服务价格的快速上涨,加上农村医疗保障制度的缺位,使得患者面临沉重的医疗负担,尤其是在遭受大病冲击时,将迫使农民陷入贫困的境地。
研究内容二：疾病与贫困作用关系的微观描述
健康与贫困相互作用形成恶性循环。利用CHNS的追踪数据本文探讨了疾病与贫困间的相互关系及动态发展过程。从静态角度分析,我国农村贫困与健康贫困状况不断得到改善,但也存在反复与波动；贫困户更易受到健康冲击,对医疗服务的有效需求不足,医疗负担过重；由于医疗保障制度的缺失以及医疗价格的高涨,疾病仍然是我国农村致贫的重要原因之一,因此克服贫困与健康贫困任重而道远。立足于动态发展过程,农村因病致贫与因贫致病的恶性循环现象逐步得到改善,家庭健康冲击在短期内给家庭造成的影响更大,致使家庭陷入暂时性的贫困境地,而给家庭带来的长期影响要小得多。
研究内容三：健康冲击对贫困及动态贫困影响的实证研究
本章重点利用微观数据分别从静态和动态的视角探讨健康冲击对贫困及贫困动态变化的影响,得到的基本结论是：其一,健康冲击将加大农户陷入贫困的概率,且年份越近,影响越大。在运用工具变量法和面板数据模型控制内生性后均发现,在不考虑内生性问题时,健康冲击对农户贫困的影响被低估；其二,健康冲击一方面增大了贫困农户脱贫的脆弱性,另一方面加大了非贫困户进入贫困的风险,因此对退出贫困的影响为负,而对进入贫困以及保持贫困的影响为正；其三,健康冲击不仅在短期内对贫困产生影响,而且会影响家庭长期收入水平的增长,在长期内影响贫困。相对而言,健康冲击对短期贫困的影响较大,而对长期贫困的影响略微有所减小。
研究内容四：新农合制度对缓解“因病致贫”的作用效果
新型农村合作医疗制度是一种正式的风险应对机制,其缓解“因病致贫”的作用主要通过对农户自费医疗支出的补偿来实现。本文对新农合制度缓解“因病致贫”作用效果的研究结果显示：新农合制度能够在一定程度上缓解因病致贫,符合制度设计的初衷,但效果并不十分明显。而且新农合制度对不同收入人群缓解因病致贫的效果存在不均等性,低收入阶层从新农合制度中的受益程度要小于较高收入阶层。
研究内容五：社会网络内风险统筹机制对缓解因病致贫的影响
在“关系本位”的农村社会,农户的行为遵循“生存伦理”和“互惠”的原则,以血缘、亲缘或地缘关系为纽带形成的农户社会关系网络组成一个风险分担团体,起着非正式的风险保障作用,为个体农户在遭受健康冲击后提供最后一道防线。文中将亲友馈赠作为社会网络内风险统筹机制,通过在模型中引入亲友馈赠价值与健康冲击的交叉项分析其对缓解因病致贫的实际效果。分析结果显示,亲友馈赠能够减缓经济贫困,但对于缓解因病致贫的作用不明显。
Farmers, as the basic economic unit in China, have to face various risks in the process of production and consumption, and in all of the risk set, disease risk is more serious and far-reaching. That the large medical expenses exceed the family paying ability, will result in poverty from the perspective of income, called "impoverished by hospitalization", or "fell back into poverty due to illness". However, from the perspective of feasible competence, the poverty caused by disease is not just income poverty, more importantly, but also the deprivation of feasible competence which reduces the income earning ability, and makes it more difficult to transfer the income into feasible competence. Therefore, the real poverty produced by disease is more serious than the poverty shown in income space, and it may have persistence, or even inter-generational transmission.
While in the face of welfare losses from healthy problems, farmers deal with them actively through a variety of ways, rather than accept it passively. Farmers'risk coping mechanism includes the formal and the informal. In the situation of imperfect formal health insurance system, it is the "rational choice" for farmers to adopt the informal coping mechanism to resolve economic risks from the disease.
Risk, risk exposure, risk response or coping strategy and the welfare consequences constitute a complete risk-chain. The risk-chain starts with varieties of risks, but the existence of the risks does not directly produce a negative effect except one case, that is, the risk exposure affects the family welfare. The risk coping strategies include ex ante and ex post strategies. In this study, we will focus on health risk and we will start with the health shocks that the household suffer, and also the main consideration lies in the ex post coping strategies. We will analyze health exposure (health shocks), welfare consequences (poverty), and the coping strategies of the health risk on the whole. This paper includes two main parts:First, we'll look at the poverty in China's rural areas and analyze the impacts on the poverty of the family suffering from the health shocks, including the dynamic changes of poverty, which is the process of driving into poverty by medical crises. The second part talks about whether the two different coping strategies, the formal one and the informal one can help to buffer the process of driving into poverty by medical crises in the rural, namely the new rural cooperative medical mechanism and risk-pooling in social net. The specific contents are as follows:
Part 1:description and analysis of macro situation of poverty induced by illness
This section aims to lay the foundation of the following empirical analysis. At present, the disease has become one of the major reasons for farmers being poor. On the one hand, owing to the low income and the poor accessibility of medical services, many farmers who are suffering from diseases can't afford to see a doctor, and even stay at home while they should be hospitalized. On the other hand, the government lacks investment in health as well as the imbalanced allocation of medical resources between urban and rural areas, which leads to the capacity of farmers access to health services is far weaker than that of urban residents. The rapid rise in prices of medical services together with the absence of rural medical insurance system constitute a heavy medical burden upon the farmers, especially the impact of being ill, which will force the farmers into poverty situation.
Part 2:the micro description of the interaction between disease and poverty
Interaction between health and poverty forms a vicious circle. Using the CHNS longitudinal data, this paper discusses the inter-relationship and the dynamic development process between disease and poverty. From the static perspective, China's income poverty and health poverty in rural area is constantly improving, but there are repeated with the fluctuation. Poor households are more vulnerable to health shocks. Because of lack effective demand for medical services, their medical burden is too heavy. Due to the lack of medical insurance system and the high medical price, the disease remains a major cause of poverty in rural areas of China. Therefore, to overcome poverty and poor health, we still have a long way to go. Based on the dynamic development process, the problem of poverty caused by illness and the problem of illness caused by poverty is gradually being improved. In the short term, the impact of the health shocks is greater, resulting in families into a transient poverty situation, but in the long-term the impact is much smaller.
Part 3:the impact of health shocks on poverty and dynamic poverty
Based on micro-data, this part aims to evaluate the impact of health shocks on poverty and dynamic poverty. Three main conclusions are as follows:Firstly, probit model is used to probe into the effect of health shocks on poverty using total seven-round survey data. The problem of "poverty due to illness" is confirmed in our conclusion, and the closer the time is, the greater the effect is. Under controlling the endogeniety problem caused by omitted variables and simultaneous causality using biprobit and xtprobit model, the paper finds that the effect of health shocks on poverty is greater. Second, health shocks enhance the frangibility of poor household moving out of poverty and the risk of non-poor household moving into poverty, so the effect of health shocks is negative on moving out of poverty and positive on moving into poverty and keeping in poverty. Third, Health shocks reduce household's income in the short term, and also have negative effect on household's long term income. It has profound influence on dynamic poverty in the long term, which will induce chronic poverty and force rural household into the vicious circle of illness and poverty. Relatively, health shocks have a greater impact on poverty in the short term, while the effect is smaller in the long term.
Part 4:the influence of the New Rural Cooperative Medical System (NRCMS) on the reduction of poverty due to illness
The NRCMS is a formal risk-coping mechanism, which eases farmers'problem of "poverty due to illness" through compensation for medical expenses. This paper discusses the influence of the NRCMS on easing the problem of "poverty due to illness" using propensity score matching method. The results show that:to a certain extent, the NRCMS can reduce the poverty induced by illness, which is in line with the original intention of its design, but the effect is not very clear. In addition, the effectiveness on easing different low-income families'poverty is unequal. In other words, low-income families enjoy fewer benefits than high-income ones.
Part 5:the influence of risk-pooling in social net on the reduction of poverty due to illness
In the relationship-based rural society, farmers follow the principle of "survival ethic" and "reciprocity". So the risk-sharing group based on blood, kinship and geo-relationship plays the role of informal insurance, which provides the last defense for famers suffering from health shocks. This paper analyzes the anti-poverty induce by illness of gift giving, considered as risk-pooling in social net, by introducing cross-item of gift giving and gift-giving. The findings are that gift-giving can reduce poverty due to illness, but the effect is not significant.
面对大病冲击带来的福利的损失,农户并不只是消极地承受,而是努力通过多种途径来积极应对。农户的风险应对机制包括正式的和非正式的。在正式的健康保障制度不完善的情况下,农户依靠非正式的应对机制来化解疾病的经济风险,这也是农户的“理性选择”。
风险因素、风险暴露、风险反应或处理策略以及福利后果构成一条完整的风险链。风险链的起点是各种各样的风险,风险的存在并不会直接产生负向影响,只有当风险暴露后才会影响家庭的福利水平。风险的处理策略包括事前行为以及事后的处理策略。在本研究中,我们选取健康风险作为研究重点,并以家庭实际受到健康冲击作为研究的起点,而且主要考虑事后的风险应对策略。将健康风险暴露(健康冲击)、福利后果(贫困)以及健康风险应对策略纳入统一的分析框架。全文主要沿两条主线展开：一是从健康风险的角度审视我国农村的贫困现象,分析健康冲击对家庭贫困的影响,包括贫困的动态变化,即因病致贫的作用过程；二是选取新型农村合作医疗制度、社会网络内的风险统筹分别作为正式的和非正式的风险应对策略的研究重点,探究两种不同的应对策略能否起到缓解我国农村因病致贫的效果。具体研究内容陈述如下：
研究内容一：因病致贫的宏观现状及成因分析
该部分的目的是为后面章节的实证分析奠定研究背景。目前,疾病已成为农户致贫的重要原因之一。由于农村居民收入偏低,医疗服务的经济可及性差,出现患病不就诊,应住院而未住院的现象。而政府卫生事业投入的不足以及城乡之间医疗资源配置的不平衡,也导致农民获得医疗服务的能力远远弱于城镇居民。医疗服务价格的快速上涨,加上农村医疗保障制度的缺位,使得患者面临沉重的医疗负担,尤其是在遭受大病冲击时,将迫使农民陷入贫困的境地。
研究内容二：疾病与贫困作用关系的微观描述
健康与贫困相互作用形成恶性循环。利用CHNS的追踪数据本文探讨了疾病与贫困间的相互关系及动态发展过程。从静态角度分析,我国农村贫困与健康贫困状况不断得到改善,但也存在反复与波动；贫困户更易受到健康冲击,对医疗服务的有效需求不足,医疗负担过重；由于医疗保障制度的缺失以及医疗价格的高涨,疾病仍然是我国农村致贫的重要原因之一,因此克服贫困与健康贫困任重而道远。立足于动态发展过程,农村因病致贫与因贫致病的恶性循环现象逐步得到改善,家庭健康冲击在短期内给家庭造成的影响更大,致使家庭陷入暂时性的贫困境地,而给家庭带来的长期影响要小得多。
研究内容三：健康冲击对贫困及动态贫困影响的实证研究
本章重点利用微观数据分别从静态和动态的视角探讨健康冲击对贫困及贫困动态变化的影响,得到的基本结论是：其一,健康冲击将加大农户陷入贫困的概率,且年份越近,影响越大。在运用工具变量法和面板数据模型控制内生性后均发现,在不考虑内生性问题时,健康冲击对农户贫困的影响被低估；其二,健康冲击一方面增大了贫困农户脱贫的脆弱性,另一方面加大了非贫困户进入贫困的风险,因此对退出贫困的影响为负,而对进入贫困以及保持贫困的影响为正；其三,健康冲击不仅在短期内对贫困产生影响,而且会影响家庭长期收入水平的增长,在长期内影响贫困。相对而言,健康冲击对短期贫困的影响较大,而对长期贫困的影响略微有所减小。
研究内容四：新农合制度对缓解“因病致贫”的作用效果
新型农村合作医疗制度是一种正式的风险应对机制,其缓解“因病致贫”的作用主要通过对农户自费医疗支出的补偿来实现。本文对新农合制度缓解“因病致贫”作用效果的研究结果显示：新农合制度能够在一定程度上缓解因病致贫,符合制度设计的初衷,但效果并不十分明显。而且新农合制度对不同收入人群缓解因病致贫的效果存在不均等性,低收入阶层从新农合制度中的受益程度要小于较高收入阶层。
研究内容五：社会网络内风险统筹机制对缓解因病致贫的影响
在“关系本位”的农村社会,农户的行为遵循“生存伦理”和“互惠”的原则,以血缘、亲缘或地缘关系为纽带形成的农户社会关系网络组成一个风险分担团体,起着非正式的风险保障作用,为个体农户在遭受健康冲击后提供最后一道防线。文中将亲友馈赠作为社会网络内风险统筹机制,通过在模型中引入亲友馈赠价值与健康冲击的交叉项分析其对缓解因病致贫的实际效果。分析结果显示,亲友馈赠能够减缓经济贫困,但对于缓解因病致贫的作用不明显。
Farmers, as the basic economic unit in China, have to face various risks in the process of production and consumption, and in all of the risk set, disease risk is more serious and far-reaching. That the large medical expenses exceed the family paying ability, will result in poverty from the perspective of income, called "impoverished by hospitalization", or "fell back into poverty due to illness". However, from the perspective of feasible competence, the poverty caused by disease is not just income poverty, more importantly, but also the deprivation of feasible competence which reduces the income earning ability, and makes it more difficult to transfer the income into feasible competence. Therefore, the real poverty produced by disease is more serious than the poverty shown in income space, and it may have persistence, or even inter-generational transmission.
While in the face of welfare losses from healthy problems, farmers deal with them actively through a variety of ways, rather than accept it passively. Farmers'risk coping mechanism includes the formal and the informal. In the situation of imperfect formal health insurance system, it is the "rational choice" for farmers to adopt the informal coping mechanism to resolve economic risks from the disease.
Risk, risk exposure, risk response or coping strategy and the welfare consequences constitute a complete risk-chain. The risk-chain starts with varieties of risks, but the existence of the risks does not directly produce a negative effect except one case, that is, the risk exposure affects the family welfare. The risk coping strategies include ex ante and ex post strategies. In this study, we will focus on health risk and we will start with the health shocks that the household suffer, and also the main consideration lies in the ex post coping strategies. We will analyze health exposure (health shocks), welfare consequences (poverty), and the coping strategies of the health risk on the whole. This paper includes two main parts:First, we'll look at the poverty in China's rural areas and analyze the impacts on the poverty of the family suffering from the health shocks, including the dynamic changes of poverty, which is the process of driving into poverty by medical crises. The second part talks about whether the two different coping strategies, the formal one and the informal one can help to buffer the process of driving into poverty by medical crises in the rural, namely the new rural cooperative medical mechanism and risk-pooling in social net. The specific contents are as follows:
Part 1:description and analysis of macro situation of poverty induced by illness
This section aims to lay the foundation of the following empirical analysis. At present, the disease has become one of the major reasons for farmers being poor. On the one hand, owing to the low income and the poor accessibility of medical services, many farmers who are suffering from diseases can't afford to see a doctor, and even stay at home while they should be hospitalized. On the other hand, the government lacks investment in health as well as the imbalanced allocation of medical resources between urban and rural areas, which leads to the capacity of farmers access to health services is far weaker than that of urban residents. The rapid rise in prices of medical services together with the absence of rural medical insurance system constitute a heavy medical burden upon the farmers, especially the impact of being ill, which will force the farmers into poverty situation.
Part 2:the micro description of the interaction between disease and poverty
Interaction between health and poverty forms a vicious circle. Using the CHNS longitudinal data, this paper discusses the inter-relationship and the dynamic development process between disease and poverty. From the static perspective, China's income poverty and health poverty in rural area is constantly improving, but there are repeated with the fluctuation. Poor households are more vulnerable to health shocks. Because of lack effective demand for medical services, their medical burden is too heavy. Due to the lack of medical insurance system and the high medical price, the disease remains a major cause of poverty in rural areas of China. Therefore, to overcome poverty and poor health, we still have a long way to go. Based on the dynamic development process, the problem of poverty caused by illness and the problem of illness caused by poverty is gradually being improved. In the short term, the impact of the health shocks is greater, resulting in families into a transient poverty situation, but in the long-term the impact is much smaller.
Part 3:the impact of health shocks on poverty and dynamic poverty
Based on micro-data, this part aims to evaluate the impact of health shocks on poverty and dynamic poverty. Three main conclusions are as follows:Firstly, probit model is used to probe into the effect of health shocks on poverty using total seven-round survey data. The problem of "poverty due to illness" is confirmed in our conclusion, and the closer the time is, the greater the effect is. Under controlling the endogeniety problem caused by omitted variables and simultaneous causality using biprobit and xtprobit model, the paper finds that the effect of health shocks on poverty is greater. Second, health shocks enhance the frangibility of poor household moving out of poverty and the risk of non-poor household moving into poverty, so the effect of health shocks is negative on moving out of poverty and positive on moving into poverty and keeping in poverty. Third, Health shocks reduce household's income in the short term, and also have negative effect on household's long term income. It has profound influence on dynamic poverty in the long term, which will induce chronic poverty and force rural household into the vicious circle of illness and poverty. Relatively, health shocks have a greater impact on poverty in the short term, while the effect is smaller in the long term.
Part 4:the influence of the New Rural Cooperative Medical System (NRCMS) on the reduction of poverty due to illness
The NRCMS is a formal risk-coping mechanism, which eases farmers'problem of "poverty due to illness" through compensation for medical expenses. This paper discusses the influence of the NRCMS on easing the problem of "poverty due to illness" using propensity score matching method. The results show that:to a certain extent, the NRCMS can reduce the poverty induced by illness, which is in line with the original intention of its design, but the effect is not very clear. In addition, the effectiveness on easing different low-income families'poverty is unequal. In other words, low-income families enjoy fewer benefits than high-income ones.
Part 5:the influence of risk-pooling in social net on the reduction of poverty due to illness
In the relationship-based rural society, farmers follow the principle of "survival ethic" and "reciprocity". So the risk-sharing group based on blood, kinship and geo-relationship plays the role of informal insurance, which provides the last defense for famers suffering from health shocks. This paper analyzes the anti-poverty induce by illness of gift giving, considered as risk-pooling in social net, by introducing cross-item of gift giving and gift-giving. The findings are that gift-giving can reduce poverty due to illness, but the effect is not significant.
引文
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①转引自：张秀兰.因病致贫和因贫致病的路径分析.健康与发展国际研讨会
①转引自：张秀兰.因病致贫和因贫致病的路径分析.健康与发展国际研讨会
①明代张居正《请蠲积逋以安民生疏》
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①转引自：高云红,张建华.贫困概念的演进.改革,2006(6)：113页
①转引自：张秀兰.因病致贫和因贫致病的路径分析.健康与发展国际研讨会
①转引自：张秀兰.因病致贫和因贫致病的路径分析.健康与发展国际研讨会
①明代张居正《请蠲积逋以安民生疏》
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