| Background:Since the reform and opening in China,the government had implemented a series of health policy reforms in the field of social welfare,which had a significant impact on the improvement of residents' nutrition structure and health status.The basic medical insurance,including NRCMS(New Rural Cooperative Mdical Scheme),URBMI(Urban Residents Basic Medical Insurance)and UEBMI(Urban Employee Basic Medical Insurance),had been a unique part of Chinese social security system.It played a positive role in ensuring residents' health and maintaining social stability.On the one hand,medical insurance could increase the accessibility of medical services,on the other hand,it might increase the risk of disease.That is to say,medical insurance could reduce the cost in the treatment and decrease in the enthusiasm for personal disease prevention or in the incentives of choosing healthy lifestyle.This was called "ex-ante moral hazard" in economic theory.At present,the theoretical model of "ex-ante moral hazard" has been established at home and abroad,but the empirical research in developing countries are still lacking.At present,there is not enough research on the possible "advance moral hazard" in China's rural and urban areas,especially based on the correlation of dietary energy intake,macronutrient intake and obesity risk.Objective:This study aims to assess the participation of basic medical insurance,distribution of dietary energy intake and macronutrient composition and obesity and explore their associations among Chinese males and females.To investigate the possible phenomenon of "ex-ante moral hazard" in rural and urban areas in China.In hope for providing relevant scientific evidence for improving the medical policy and medical system construction both in China and in other developing countries.Methods:The data are derived from the CHNS(China Health and Nutrition Survey)project.According to the purpose of the study,the research objects can be divided into three categories.The first category includes 18?80 years old adults(24,442 males and 27,463 females)in nine provinces from 2004 to 2015.We analyzed the status and trends of basic medical insurance participation,dietary energy and macronutrient intake,overweight,obesity and central obesity.The second category included the rural adult residents who participated in at least one round of surveys from 2004 to 2015,including 12,722 males and 14,438 females.OLS(Ordinary Least Square),Probit and ?(Instrumental Variable)model were conducted to control the endogeneity of individual insured behavior.We explored the associations between NRCMS,dietary energy and macronutrients intake and obesity risk among adults and investigate the possible "ex-ante moral hazard" in rural areas.The third category included the urban adult residents(3,246 men and 4,122 women)who participated in al least one round of surveys from 2004 to 2015,excluding urban adults with other insurance and complete data.We explored the associations between URBMI,dietary energy and macronutrients intake and obesity risk among adults and investigate the possible "ex-ante moral hazard" in urban areas.Results:1.From 2004 to 2015,the insured rate of Chinese adult residents' basic medical insurance increased significantly.NRCMS participation of male resisdents increased from 7.8%to 51.5%,and female increased from 7.7%to 54.1%.UEBMI participation of male resisdents participation rate increased from 20.5%to 28.6%,and female increased from 16.6%to 24.2%.The rate of male URBMI participation increased from 8.9%in 2009 to 51.5%in 2015,and the number of female URBMI increased from 11.4%in 2009 to 19.5%in 2015.By 2015,the basic medical insurance of residents is almost full coverage.2.From 2004 to 2015,the dietary energy,fat,protein,carbohydrate intake and the percentage of energy from carbohydrate of NRCMS participants decreased year by year,while the percentage of energy from fat increased from 29.2%to 34%.The BMI(Body Mass Index),the WC(Waist Circumference),the obesity rate and the central obesity rate were increasing year by year.In 2015,the obesity rate and central obesity rate were 14%and 39%,respectively.3.From 2009 to 2015,the energy and carbohydrate intake of the URBMI insured participants showed a general declined trend.The WC,BMI,obesity rate and central obesity rate of the insured residents were increasing year by year.In 2015,the obesity rate and central obesity rate were 15%and 46%,respectively.4.Compared with the AMDR(Acceptable Macronutrient Distribution Ranges),in 2015 the percentage of energy from fat in the range of AMDR(20 to 30%)of males and females were 23.6%and 23.1%,respectively;the the percentage of energy from fat exceeded the AMDR range(>30%)of males and females were 67.4%and 67.5%,respectively.The percentage of energy from carbohydrate in the range of AMDR(50 to 65%)of males and females were 37,8%and 39.4%,respectively;The percentage of energy from carbohydrate lower than AMDR range(<50%)of males and females were 50.3%and 47.7%,respectively.5.From 2004 to 2015,the BMI and WC of Chinese adults showed an increasing trend year by year.In 2015,the BMI and WC of male were 24.3 kg/m2 and 86.3 cm,respectively.The BMI and WC of female were 24.1 kg/m2 and 81.8 cm,respectively.The overweight rate,obesity rate and central obesity rate of adults were increasing year by year.In 2015,the overweight rate,obesity rate and central obesity rate of male adults were 36.8%,13.7%and 39.4%,respectively,and of female adults were 33.5%,13.8%and 40.4%,respectively.6.From 2004 to 2015,controlling endogeneity with instrument variables,the OLS-IV model suggested that in males,NRCMS has a coefficient of energy 75.21(P<0.10),fat 18.18(P<0.001),carbohydrate-32.23(P<0.001),fat energy supply ratio 5.88(P<0.001),carbohydrate energy supply ratio-6.86(P<0.001),sitting time2.69(P<0.001)and WC-0.02(P<0.001)and BMI 0.09(P<0.001).The results of IV-Probit model suggested that in males,the marginal effects of NRCMS were smoking 0.05(P<0.05),drinking-0.01,obesity 0.24(P<0.001)and central obesity 0.04.7.From 2004 to 2015,controlling endogeneity with instrument variables,the OLS-IV model suggested that in females,NRCMS has a coefficient of fat 15.66(P<0.001),carbohydrate-39.96(P<0.001),fat energy supply ratio 6.84(P<0.001),carbohydrate energy supply ratio-6.71(P<0.001),sitting time 3.62(P<0.001),WC 0.48(P<0.001)and BMI 0.54(P<0.001).The results of ?-Probit model suggested that in males,the marginal effects of NRCMS were smoking 4.14(P<0.001),drinking-0.01,obesity 3.72(P<0.05)and 4.25(P<0.001).8.From 2004 to 2015,controlling endogeneity with instrument variables,the OLS-? model suggested that in males,URBMI has a coefficient of energy 79.65,fat 3.20,carbohydrate 5.03,fat energy supply ratio 0.56,carbohydrate energy supply ratio-0.15(P<0.001),sitting time 1.84 and WC 3.28(P<0.05)and BMI 0.78(P<0.001).The results of ?-Probit model suggested that in males,the marginal effects of NRCMS were smoking-0.20(P<0.05),drinking-0.14(P<0.05),obesity 0.22 and central obesity 0.23.9.From 2004 to 2015,controlling endogeneity with instrument variables,the OLS-IV model suggested that in females,URBMI has a coefficient of energy-18.20,fat 0.94,carbohydrate-7.65,fat energy supply ratio 0.38,carbohydrate energy supply ratio-0.89,sitting time 1.97,WC 0.66 and BMI-0.01.The results of IV-Probit model suggested that in males,the marginal effects of NRCMS were smoking-0.01,drinking 0.03,obesity-0.01 and central obesity-0.02.Conclusion:From 2004 to 2015,the overall medical insurance participation rate of adult residents in China had increased year by year,and the dietary structure showed decrease trend in energy intake,but the fat supply ratio showed increased year by year,meanwhile,overweight,obesity and central obesity of adult had increased significantly.In the process of promoting the comprehensive coverage of medical insurance,the phenomenon of "ex-ante moral hazard" is common in the rural areas of China.The NRCMS had significantly changed the individual life style,and had increased the unhealthy tendency of smoking,sedentary,high energy,high fat diet and so on,and had increased the risk of obesity. |
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