| As a part of social basic security,health service plays an important role in people’s welfare.According to welfare economics and equalitarianism,health system should pursue the goal of equity and serve to improve people’s health.Health equity theory generally includes health financing,utilization and health equity.Financing is the premise of health service and health is the purpose of health service.Many countries and regions have carried out various forms of health system reform to achieve the goal of health equity,among which the insurance system is an important part.In order to share individual risks,the insurance system sets up a common responsibility system,which will protect the interests of the insured and contractors through the law of large numbers,and share the risks of the insured,so as to improve individual consumption capacity.China’s insurance system is full coverage,can improve every citizen’s access to health services and personal health degree,to protect citizens’ basic right to health.Although the accessibility of health services has been guaranteed through the improvement of coverage,there are many aspects of health services showing differences between urban and rural areas or between regions,such as a series of inequities in health financing,health service use and health.The imbalance of health services between urban and rural areas and between regions not only affects people’s health,but also brings a series of social problems.In this context,China began to vigorously implement the urban-rural overall basic medical security policy(hereinafter referred to as overall medical insurance).Overall medical insurance is an insurance form that combines the original urban residents’ basic medical insurance with the new rural cooperative basic medical insurance owned by rural residents.It was established to address inequities in the health system caused by household registration barriers.Based on the basic principle of “promoting health service equity”,existing domestic literature has carried out a series of studies on policy evaluation of integrated medical insurance.However,in general,these literatures have not comprehensively explored the effect of integrated medical insurance.For example,there are more analyses on equity in medical use,but less discussions on equity in financing and health in health equity.The period of rapid development of health financing started from 2015,but the existing literature generally uses data before 2015,which leads to inadequate research on the stage of comprehensive rollout of the integrated medical insurance.Most of the data used in this study are small-scale survey data,and there are few evaluations on the process of nationwide integrated medical insurance,existing problems and policy effects.In the process of the study,basic issues such as the participation decision of the unified medical insurance were not discussed,and some important issues were ignored.For example,in addition to affecting the equity of medical use,Whether it has an impact on health financing and health,whether the implementation process of integrated health insurance is smooth,the process of integrated health insurance in the whole country,the effect of integrated health insurance after2015,the influencing factors in the implementation process of integrated health insurance,whether the integrated mode is scientific,whether the existing problems will affect its longterm development and so on.The answers to these key questions are obviously of great help for us to have a deeper understanding of the real effect of health insurance pooling policy.Therefore,based on the existing domestic research,this paper sorted out the policy development and possible problems related to the integrated medical insurance,and conducted a comprehensive and systematic study on the policy effect of the integrated medical insurance by using internationally advanced and mainstream methods.To be specific,the empirical part mainly uses the data of China Health and Retirement Longitudinal Study(CHARLS)from 2011 to2018 to analyze the influence of pooling medical insurance on health financing,utilization and health equity by combining relevant empirical methods,and analyzes the influencing factors of pooling medical insurance participation decision.Finally,corresponding policy suggestions are provided for the existing problems of the overall medical insurance,so as to make a contribution to the smooth implementation of the overall medical insurance policy in China and the realization of a greater possibility of health service equity.The empirical part of this paper mainly adopts macro data from National Statistical Yearbook and China Health and Health Statistics Yearbook,as well as micro data from China Health and Retirement Longitudinal Study(CHARLS),which conducted national surveys in2011,2013,2015 and 2018.Problems related to family,personal health and old-age care for middle-aged and elderly people aged 45 and above.So the database is nationally representative.In addition,the questionnaire has contained questions related to overall medical insurance since2011,which is one of the few micro databases in China that contain questions related to overall medical insurance.The database released survey data for 2018 at the end of September 2020,which allowed this paper to analyze the phase of universal coverage rollout,i.e.,the period after2015.The research object of this paper is representative and the data is time-sensitive.This paper mainly analyzes the middle-aged and elderly groups.The main characteristics of the middle-aged and elderly groups are: older age,lower income,more use of medical services,deep dependence on the medical security system,and people with lower socioeconomic status in the group account for a large proportion.National statistics show that the participation rate of the middle-aged and elderly in universal health insurance is lower than the national average.In general,middle-aged and elderly groups should be paid more attention by health security departments,and corresponding targeted policies should be formulated for some vulnerable groups in health system reform.The obvious differences in age and income level of middle-aged and elderly groups may affect their insurance participation behaviors.Existing studies mostly focus on the average effect of the whole age,it is easy to ignore the middle-aged and elderly this special group.For the first time,this paper systematically gives a more comprehensive evaluation and empirical test from the perspectives of equity in health financing,equity in use and equity in health.At present,there are many literatures analyzing the impact of the integrated medical insurance on health equity,but less attention is paid to health financing equity and health equity in health equity,and there are even fewer literatures evaluating the integrated medical insurance from three aspects.This paper not only does the three aspects of the investigation,but also combines the analysis results of the three.For example,this paper found that the financing inequity remained high from 2011 to 2015,and the social security channel in financing was the main factor leading to the financing inequity,which showed from a side that for the middleaged and elderly population studied in this paper,the coordinated medical insurance in 2015 and the previous years did not play its due effect.This also proves from the side that when studying the equity of medical use in Chapter 5,this paper takes 2015 as the year before pooling and 2018 as the year after pooling to conduct differential regression to test the effect of pooling medical insurance.This is the first contribution of this paper.This is the first time to systematically examine what factors affect the participation of urban and rural integrated medical insurance in China,but there are few studies on relevant issues.Based on the study of the influence factors of the elderly ginseng,mechanism of overall health care Settings and operating conditions were analyzed,and the results showed that high social and economic status of ginseng probability significantly higher,most of the elderly after retirement income less,low socioeconomic status,it is probably is the reason why the group as a whole medical insurance participation is low,The empirical results also show that adverse selection exists in the decision of insurance participation.Policy as a whole in order to further analysis on the ginseng incentive effect,we analyzed the overall health care financing way for the elderly to participate in making and the effect of study of more than a leg and a system file two financing ways of the influence of the elderly health insurance as a whole to participate in the decision,the results showed that two kinds of financing methods all have positive significant effect,And the incentive effect of one system and many files is greater than that of one system.Improving the participation rate of the overall medical insurance can promote the balanced allocation of resources and the smooth transition of medical insurance policies between urban and rural areas,different income groups and different regions.We should adhere to and improve the financing mode of one system and multiple tiers to ensure the rapid and steady progress of the overall medical insurance system.These basic researches in the operation of the integrated medical insurance policy will have certain reference value to the implementation of relevant departments.This is the second contribution of this paper.In terms of structure,the whole paper consists of eight chapters,among which the first chapter is the introduction,and the second and third chapters provide theoretical and model basis for the following empirical analysis.The second chapter is a review of the theories of health equity,the research results of health equity at home and abroad and the related research of medical insurance system.The third chapter is an overview of the background of the insurance system,which explains the background,specific regulations and progress of the establishment of the overall medical insurance.Chapter four to chapter eight is the empirical analysis and policy suggestions of policy evaluation based on China’s specific national conditions.The fourth chapter analyzes the equity of health financing in time and space.Chapter five examines the effect of urban and rural integrated medical insurance in China from the perspective of health service equity.Chapter six studies the impact of health insurance on health and health inequity from the perspective of health equity.The seventh chapter mainly analyzes the influencing factors of insurance participation and the incentive effect of the pooling medical insurance financing system.The eighth chapter is the policy suggestion part of this paper.The implementation of the overall medical insurance policy has improved the fairness of China’s health system,but there are still some problems,this paper puts forward relevant policy suggestions.From the health services in the second chapter belongs to welfare economics,from philosophy to explore the characteristics of public goods to achieve the purpose of the fair,the third chapter through to the insurance system reform,to explain why set a fair opportunity in overall health care and their goal,the combination of the two chapter reflects this paper studies the source of the topic.In the following three chapters,the empirical analysis verifies step by step that pooling medical insurance can improve the equity of health financing,utilization and health,which verifies that “joining pooling medical insurance improves health equity”.The second chapter summarizes the problem that insurance is prone to “adverse selection” by combing the literature.In chapter 3,through sorting out insurance policies,it is found that the process of overall medical insurance lags seriously behind the requirements of national policy deployment,which is reflected in the low participation rate of insured people and the slow implementation speed of local health security process.Through the empirical tests in Chapter5 and Chapter 6,this paper finds that the overall medical insurance does have some problems such as low participation rate and low degree of improvement in health service inequity,and verifies that “there are still some problems in the current overall medical insurance”.At the end of this paper,combined with the development experience and lessons of the original insurance system in Chapter 3 and the exploration of the participation decision of the overall medical insurance in Chapter 7,suggestions are put forward to accelerate the process of the overall medical insurance,improve the participation rate of the overall medical insurance,and improve the security level and level of the overall medical insurance.Specifically,the second chapter is the theory and literature review.Firstly,it summarizes the western health equity theories,including public goods theory,welfare economics theory,maximum and minimum theory,egalitarianism theory and equal opportunity theory,to lay a theoretical foundation and provide a thinking framework for constructing equity system and evaluating the effect of overall policy.Secondly,the empirical literature on health equity is reviewed.Finally,the literature related to insurance policy evaluation is reviewed.The third chapter is mainly about the background of relevant insurance system.First of all,the background of the birth of the overall medical insurance and the parallel situation of the three medical insurance systems and the resulting contradictions are explained.Secondly,the establishment of the overall medical insurance,coverage of the population,financing and subsidies,security situation;Finally,compared with the original insurance type,the advantages and existing main problems of overall medical insurance are explored.The fourth chapter explores the equity of health financing.The paper focuses on the development of spatial and temporal inequity in health financing of middle-aged and elderly groups in China from 2011 to 2015,uses the widely recognized decomposition method of tax redistribution to decompose the fairness of health financing,and finally focuses on the vertical redistribution effect in the redistribution effect.The overall medical insurance policy proposed by the reform of medical insurance system will have a great impact on the existing social security channels.It can be predicted that once the financing of the same financing platform is guaranteed to be the same,the existing inequity of urban and rural health financing will be alleviated.The implementation of integrated medical insurance emerged at the right moment.For middle-aged and elderly people,reducing the regressivity of the three channels and controlling the rise of medical expenditure should be promoted in parallel,and the integration of urban and rural medical insurance should be promoted steadily,so as to narrow the vertical inequity caused by the difference of insurance system.The fifth chapter studies the influence of the pooling medical insurance on the equity of health use,and applies the equality of opportunity theory and differential difference model to quantitatively study the influence of pooling policy on the inequality of medical use opportunity of middle-aged and old people in urban and rural areas,and analyzes the influence of the age of the insured on the participation of health insurance.The sixth chapter studies the impact of universal medical insurance on health and its inequity,extending the scope of sample survey to2011 to 2018.Firstly,the impact of universal medical insurance on health is analyzed through regression and instrumental variable method,and then the impact of universal medical insurance on health inequity is studied by using centralized index and index decomposition method.The seventh chapter explores the influencing factors of insurance participation decision,verifies the hypothesis and conjecture of the determinants of insurance participation mentioned above,and analyzes the difference of insurance participation incentive for middle-aged and old people by different pooling modes.Through the above studies,this paper draws the following conclusions:1.For middle-aged and elderly people,inequality in health financing has worsened,with increasing disparities between and within urban and rural areas.The improvement of health financing inequity is mainly reflected in the increase of vertical inequity,especially in social security and private insurance,where vertical inequity accounts for a large proportion.On the one hand,the phenomenon of vertical unfairness stems from the fact that all the three channels are regressive,and the regressive degree shows a slight increase.On the other hand,due to the significant increase in the proportion of all channels in the income,that is,medical costs and health expenditure have increased significantly.In 2015,urban residents invested more in health expenditure,especially social security,resulting in greater inequality in urban areas than in rural areas.With the development of economy and the increase of medical expenses,the equity of health financing increases,especially the channels represented by social security have a relatively large contribution to this inequity.The establishment of pooling equity will be a great impact to change the current unfair situation.Based on the law of large numbers,it will have a good impact on the equity of financing and the operation of the merged fund.2.The inequality of access to medical care for middle-aged and elderly people participating in the overall medical insurance has been improved,and this improvement is more obvious in outpatient service.The overall medical insurance policy has an improvement effect on the inequality of access to outpatient service for middle-aged and elderly people in urban and rural areas,but the effect is not significant for hospitalization.The impact of the pooling policy on the inequality of medical access in urban and rural areas is related to age,and the younger people are more affected by the pooling policy.3.Integrated medical insurance improves the overall health status of middle-aged and elderly groups,alleviates health inequity,and the effect keeps increasing over time.However,the effect of overall medical insurance is relatively small,which is a problem to be explored in the future.Moreover,the effects of instrumental variables on health inequity are opposite before and after the use of instrumental variables,which indicates that there are endogenous problems in the decision of participation in universal health insurance.Based on the analysis of context,it is likely that adverse selection exists.It is also likely that the lower participation rate is related to the lower role of universal coverage.4.Through the analysis of factors influencing whether residents participate in insurance,we find that the participation rate of low-income groups is low,and individuals with poor health status are more likely to participate in the overall medical insurance.On the one hand,this shows that low-income people are still at a disadvantage in medical security.On the other hand,the influence of health status on insurance decision shows the existence of “adverse selection”.This reflects from the side that the low participation rate of the middle-aged and old people in the overall medical insurance and the phenomenon of surrender are due to the institutional arrangement of the overall medical insurance policy itself.Policy as a whole in order to further analysis on the ginseng incentive effect,we analyzed the overall health care financing way for the elderly to participate in making and the effect of study of more than a leg and a system file two financing ways of the influence of the elderly health insurance as a whole to participate in the decision,the results showed that two kinds of financing methods all have positive significant effect,And the incentive effect of one system with multiple files on overall insurance participation is greater than that of one system with one gear;Having an urban hukou promotes the development of a multi-tiered system;The provinces in central China are not enough to improve the participation rate of overall medical insurance by using one system and multiple files.5.In order to improve the overall medical insurance policy,it is suggested to implement some intervention policies to improve it: voluntary participation in the overall medical insurance gradually transition to compulsory participation,so that more vulnerable groups of residents can participate in the overall medical insurance;Improve the coverage of the overall medical insurance,improve the enthusiasm of different groups to participate in the insurance;On the basis of ensure the participation rate,improve the level of overall health care financing and payment proportion is scientific,meet the demand of diversification,improve the overall health care participation can promote between the city and countryside,between different income groups,between different regions resources equilibrium configuration and health policy smooth transition,should stick to and perfect the system of multiple ways of financing,We will ensure faster and more steady progress in the coordinated medical insurance system.Improve the quality of medical services at county and village level,improve the guarantee quality of overall medical insurance;Improve the level of overall planning,reflecting the high level of overall planning. |
PDF Full Text Request